UBBABT 

OF   THE 

^fitwtsitg  of  California, 

♦- 

Name  of  Book  and  Volume, 

Division ft..Vr..y. 

Range  , 0. 

\ 

Shelf.... 

Received. X^. 1 87  J— 


»  OCKEEJ 

CASE 


LECTURES 


DISEASES 


INFANCY    AND    CHILDHOOD. 


CHARLES    WEST,    M.  D. 


fellow    op    the    royal    college    of    physicians  ; 

physician  to   the   hospital  fob-   sick   children; 

physician  -  accoucheur    to,    and    lecturer    on    midwifery    at, 

saint    Bartholomew's    hospital. 


SECOND    AMERICAN, 

FROM   THE    SECOND  AND  ENLARGED  LONDON  EDITION. 


PHILADELPHIA: 
BLANCHARD    AND    LEA 

1854. 


]a 


<i>\* 


^ 


I 


TO 


SAMUEL    STEPHENS    MARLING,  Esq. 

OF 

EBLEY,    near    STROUD, 

GLOUCESTERSHIRE, 

Ifyese   |Lecfqt*es  %H  Qctktf&fi 

IN    ACKNOWLEDGMENT    OP    THE    EVER    ACTIVE    FRIENDSHIP, 

AND   MORE  THAN  BROTHERLY  KINDNESS, 

WHICH  HAVE  MADE  A  LIPE-LONG    DEBTOR 

OF   HIS 

AFPECTIONATE     KINSMAN, 

THE  AUTHOR. 

i 

\ 


ADVEKT1SEMENT 


TO    THE    SECOND    EDITION. 


In  the  preparation  of  the  Second  Edition  of  these  Lectures,  the 
whole  work  has  been  carefully  revised :  a  few  formulae  have  been 
introduced,  and  a  minute  alphabetical  index  has  been  appended: 
while  additions,  amounting  altogether  to  fifty  pages,  have  been  made 
wherever  I  felt  that  more  extended  observation,  or  more  careful  reflec- 
tion, had  enabled  me  to  supply  some  of  those  deficiencies  which,  I  am 
well  aware,  are  still  far  too  numerous.  The  work  now  contains  the 
results  of  640  observations,  and  199  post-mortem  examinations,  chiefly 
made  among  16,276  children  who  came  under  my  notice  during  the 
ten  years  of  my  connection  with  the  Children's  Infirmary  in  Lambeth. 

Should  hereafter  a  third  edition  be  called  for,  I  trust  to  prove  that 
I  have  not  been  unmindful  of  the  duties  and  responsibilities  imposed 
on  me  by  the  honour  of  being  appointed  one  of  the  medical  officers  to 
the  Hospital  for  Sick  Children  ;  an  institution  which,  it  is  hoped,  will 
henceforth  afford  to  the  profession  a  field  for  the  minute  and  accurate 
observation  of  the  diseases  of  early  life,  such  as  neither  dispensary 
nor  private  practice  can  offer  even  to  those  most  earnest  in  the 
cultivation  of  medical  knowledge. 


96  Wimpole  Street, 

December  20,  1851. 


PREFACE 


TO    THE    FIRST    EDITION 


The  substance  of  a  considerable  part  of  the  following  Lectures  was 
addressed  to  the  pupils  of  the  Middlesex  Hospital  in  the  summer  of 
1847,  and  the  form  of  lectures  appeared  to  me  to  present  advantages 
which  led  me  to  retain  it,  when  I  determined  to  publish  the  results  of 
my  observations  on  Children's  Diseases. 

These  observations  were  made  in  the  large  field  presented  by  the 
Children's  Infirmary,  which  was  first  thrown  open  to  me  in  the  year 
1839,  by  the  kindness  of  my  friend  Dr.  Willis,  then  physician  to  that 
institution ;  to  which  office  I  succeeded  on  his  resignation  in  1842. 
Very  nearly  14,000  children  have  thus  been  brought  under  my  notice 
during  the  past  nine  years ;  and  I  have  kept  accurate  notes  of  the 
diseases  of  600,  as  well  as  of  the  results  of  180  dissections  of  cases 
in  which  those  diseases  terminated  fatally. 

The  time  that  has  elapsed  since  the  appearance  of  these  Lectures  in 
the  Medical  Gazette,  has  been  too  short  to  allow  me,  in  preparing 
them  for  separate  publication,  to  do  much  toward  supplying  those 
deficiencies  in  them  of  which  I  am  fully  sensible.  If  life  and  health 
be  spared  me,  it  will  be  my  constant  endeavour  to  render  those  imper- 
fections less  numerous.  I  trust  they  may  not  be  of  a  nature  to  detract 
seriously  from  the  usefulness  of  the  work ;  still  less  of  a  kind  to  lead 
into  error  those  to  whom  it  has  been  my  earnest  wish  to  prove  myself 
a  faithful  guide. 


Wimpolb  Street, 

September  20,  1848. 


CONTENTS 


LECTURE 
I. 
II. 

III. 

IV. 

V. 

VI. 
VII. 

VIII. 
IX. 
X. 

XI. 

XII. 
XIII. 

XIV. 
XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 


XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 
XXVI. 


PAGE. 

Introduction  17 

Diseases  of  the  Brain  and  Nervous  System.     General  remarks  upon  them, 

and  on  their  symptoms  in  early  life  26 

Congestion  of  the  Brain,  its  causes,  symptoms,  and  treatment  34 

Cerebral  Haemorrhage  and  Cephalhematoma,  or  haemorrhage  external  to 

the  skull  46 

Inflammatory  Affections  of  the  Brain.     Acute  Hydrocephalus,  its  morbid 

appearances  and  symptoms  56 

Acute  Hydrocephalus,  concluded:  its  symptoms  and  treatment  69 

Simple  Inflammation  of  the  Brain.     Inflammation  succeeding  to  Disease  of 

the  Ear.     Inflammation  of  the  Sinuses  of  the  Dura  Mater  82 

Chronic  Hydrocephalus  90 

Hypertrophy  and  Atrophy  of  the  Brain  101 

Hydrocephaloid  Disease.     Tubercle  of  the  Brain.     Hydatids  and  Cancer  of 

Brain  110 

Diseases  of  the  Spinal  Cord.     Irritation  and  Congestion.    Inflammation  of 

its  Membranes  and  Substance.     Trismus  122 

Night  Terrors.    Epilepsy.     Chorea.     Paralysis.     Facial  Hemiplegia  133 

Diseases  of  the  Respiratory  Organs  :  general  remarks  on  the  respiratory 

functions  in  early  life.     Imperfect  Expansion  of  the  Lungs  146 

Collapse  of  Lung  after  Birth.     Induration  of  the  Cellular  Tissue  157 

Inflammation  of  Respiratory  Mucous  Membrane.  Catarrh.  Coryza.  Post- 
mortem appearances  of  Bronchitis  166 

Inflammation  of  Substance  of  Lung :  its  post-mortem  appearances.  Symp- 
toms and  treatment  of  Bronchitis 176 

Pneumonia:  its  symptoms  and  treatment  191 

(Edema  of  the  Lungs.    Gangrene  of  the  Lung.    Pleurisy,  acute  and  chronic  203 
Croup:  its  varieties,  causes,  post-mortem  appearances.     Symptoms  and 

treatment  of  its  early  stages  213 

Croup :  treatment  of  its  advanced  stages — tracheotomy.  Diphtheritis  as 
a  primary  affection,  and  as  a  complication  of  measles.  Laryngitis  Stri- 
dula,  or  Croup  with  predominance  of  spasmodic  symptoms.     Varieties 

of  Spasmodic  Croup  226 

Spasm  of  the  Glottis  239 

Hooping-cough:  symptoms  and  Complications  250 

Hooping-cough :  its  complications,  continued — post-mortem  appearances, 

and  treatment  263 

Pulmonary  Phthisis :  its  peculiarities,  anatomical  characters,  and  symp- 
toms in  childhood.     General  symptoms  of  Bronchial  Phthisis,  and  of 

Phthisis  in  early  Infancy  278 

Phthisis,  continued :  its  auscultatory  signs,  its  different  forms,  duration 

and  treatment  284 

Diseases  of  the  Heart 303 


8  CONTENTS. 

LECTURE.  PAGE. 

XXVII.     Diseases  of  Organs  of  Digestion  and  Assimilation.     General  remarks  on 

the  Diet  of  Infants  323 

XXVIII.     Infantile  Atrophy.     Thrush.     Dentition,  and  the  Management  of  Chil- 
dren during  it 334 

XXIX.     Stomatitis — follicular,  ulcerative,  and  gangrenous.     Cynanche  Tonsil- 
laris.    Hypertrophy  of  the  Tonsils.     Cynanche  Parotidea  345 

XXX.     Diseases  of  the  Stomach.    Indigestion.     Softening  of  the  Stomach. 

Hsematemesis  and  Mehena  358 

XXXI.     Jaundice.     Constipation,  and  mechanical  causes  for  it,  as  imperforate 

anus  and  intussusception  371 

XXXII.     Diarrhoea :  its  symptoms  and  morbid  appearances  381 

XXXIII.  Diarrhoea,  continued:  its  treatment,  and  that  of  its  complications 392 

XXXIV.  Peritonitis,  its  acute  and  chronic  forms.    Tubercular  peritonitis.  Tabes 

mesenterica 402 

XXXV.     Intestinal  Worms.     Diseases  of  the   Urinary   Organs :    albuminuria, 

gravel,  and  calculus.     Diabetes.     Incontinence  of  Urine  .?;...  416 

XXXVI.     Abdominal  Tumors.     Infantile  Syphilis.     Discharges  from  the  Vulva 

in  Children  430 

XXXVII.     Fevers :  general  remarks  on  them.     Simple  or  Remittent  Fever :  its 

symptoms  and  treatment 443 

XXXVIII.     Small-pox.     Modified  Small-pox.      Chicken-pox  455 

XXXIX.     Measles  and  Scarlatina  464 


Index  to  the  Subjects  477 

Index  to  theFormulse  487 


LECTURES 


ON   THE 


DISEASES  OF  INFANCY  AND   CHILDHOOD. 


INTRODUCTORY  LECTURE. 

Causes  of  peculiarities  presented  by  diseases  in  childhood — These  peculiarities  are 
reasons  for  their  special  study — Difficulties  of  their  study,  and  how  to  overcome 
them — Rules  for  the  examination  of  sick  children,  and  for  taking  notes  of  Cases. — 
General  plan  and  objects  of  the  Course. 

Gentlemen, 

It  is  not  without  hesitation  that  I  have  determined  on  adding 
another  to  the  already  numerous  courses  of  lectures  that  you  are 
called  on  to  attend  while  engaged  in  the  study  of  medicine.  My 
reasons — and  I  trust  my  justification — for  so  doing  are  furnished 
partly  hy  the  frequency  of  the  diseases  of  infancy  and  childhood, 
partly  by  their  fatality,  but  still  more  by  their  many  peculiarities. 

Children  will  form  at  least  a  third  of  all  your  patients,  and  so 
serious  are  their  diseases,  that  one  child  in  five  dies  within  a  year  after 
birth,  and  one  in  three  before  the  completion  of  the  fifth  year.  These 
facts,  indeed,  afford  conclusive  arguments  for  enforcing  on  you  the 
importance  of  closely  watching  every  attack  of  illness  that  may  invade 
the  body  while  it  is  so  frail;  but  they  alone  would  scarcely  be 
adequate  reasons  for  my  bringing  these  diseases  under  your  notice  as 
objects  for  special  study. 

The  body,  however,  is  not  only  more  frail  in  infancy  than  it 
becomes  in  after  life,  but  the  sympathies  between  its  different  parts 
are  more  extensive  and  more  delicate.  One  organ  seldom  suffers 
alone,  but  the  effects  even  of  local  diseases  extend  to  the  whole 
system,  and  so  disorder  its  workings  that  it  is  often  no  easy  matter 
to  determine  the  seat  of  the  original  mischief.  Nor  is  this  all ;  but 
many  important  consequences  result  from  the  period  of  childhood 
being  one  of  unceasing  development.  In  the  adult  the  structure  of  the 
body  is  complete,  and  its  functions  are  the  same  to-day  as  they  were 
yesterday,  but  the  child  learns  successively  to  breathe,  to  feel,  to 
think :  and  its  body  is  daily  undergoing  modifications  to  fit  it  for  new 
duties,   as   well   as   daily  growing  in   size   and    strength.     Disease, 

2 


18  PECULIARITIES   OF   THE   DISEASES   OF   CHILDREN.  — 

therefore,  not  merely  disturbs  the  present,  but  its  influence  reaches  to 
the  future ;  it  not  only  interrupts  the  present  function  of  the  organ 
that  is  affected,  but  it  puts  a  stop  for  a  time  to  the  completion  of  the 
general  machinery  of  the  body,  or  disarranges  the  due  proportion  of 
one  part  of  that  machinery  to  another.  Moreover,  there  are  periods, 
namely,  those  of  the  first  and  secoDd  dentition,  when  very  great 
changes  take  place  in  the  organism  of  the  child,  and  when  all  these 
dangers  are  especially  to  be  feared.  Disease  is  then  frequent  and 
serious  beyond  what  it  is  at  other  times,  and  every  ailment  then 
warrants  a  double  measure  of  anxiety;  while,  on  the  other  hand,  if 
these  epochs  are  safely  passed,  there  succeeds  a  season  of  comparative 
immunity  from  many  affections  that  before  were  both  common  and 
perilous. 

But,  if  this  be  so,  you  will  at  once  perceive  that  something  more  is 
essential  to  the  successful  treatment  of  children's  diseases  than  to 
watch  their  advances  carefully,  and  to  adapt  the  strength  and  doses  of 
your  remedies  to  the  tender  years  of  your  patients.  It  is  not  mere 
hyperbole  to  say  that  you  have  to  study  a  new  semeiology,  to  learn  a 
new  pathology,  and  new  therapeutics.  Matters  of  such  importance 
cannot  be  properly  examined  at  the  end  of  a  course  of  lectures  on 
midwifery.  I  have  therefore  preferred  making  them  the  subjects  of 
separate  consideration  during  the  summer,  when  the  comparative 
leisure  of  the  season  will,  I  hope,  enable  you  to  devote  some  of  your 
time  to  the  practical  as  well  as  the  theoretical  study  of  the  diseases  of 
children. 

I  must  warn  you,  however,  of  one  difficulty  which  you  will  encounter 
at  the  very  onset, — a  difficulty  that  disheartens  many,  and  makes 
them  abandon  in  despair  the  study  of  children's  diseases.  Your  old 
means  of  investigating  disease  will  here  to  a  great  degree  fail  you,  and 
you  will  feel  almost  as  if  you  had  to  learn  your  alphabet  again,  or  as 
if,  entering  a  country  whose  inhabitants  you  expected  to  find  speaking 
the  same  language,  and  having  the  same  manners  as  the  people  in  the 
land  you  had  lately  left,  you  were  to  hear  around  you  everywhere  the 
sounds  of  a  foreign  tongue,  and  to  observe  manners  and  customs  such 
as  you  had  never  seen  before.  You  cannot  question  your  patient ;  or 
if  old  enough  to  speak,  still,  through  fear,  or  from  comprehending  you 
but  imperfectly,  he  will  probably  give  you  an  incorrect  reply.  You 
try  to  gather  information  from  the  expression  of  his  countenance,  but 
the  child  is  fretful,  and  will  not  bear  to  be  looked  at ;  you  endeavour 
to  feel  his  pulse,  he  struggles  in  alarm :  you  try  to  auscultate  his  chest, 
and  he  breaks  out  into  a  violent  fit  of  crying. 

Some  practitioners  never  surmount  these  difficulties,  and  the  diseases 
of  children  are  consequently  a  sealed  book  to  them.  After  a  time  they 
grow  satisfied  with  their  ignorance,  and  will  then  with  the  greatest 
gravity  assure  you  that  the  attempt  to  understand  these  affections  is 
useless.  They  have  fallen  into  this  unfortunate  error  from  not  taking 
the  pains  to  start  aright :  they  have  never  learned  how  to  interrogate 
their  little  patients,  and  hence  they  have  never  received  satisfactory 
replies.  I  speak  of  interrogating  them  ;  for  though  the  infant  cannot 
talk,  it  has  yet  a  language  of  its  own,  and  this  language  it  must  be  your 


EXAMINATION   OF   SICK   CHILDREN.  19 

first  object  to  learn,  if  you  mean  ever  to  acquire  the  character  of  suc- 
cessful practitioners  in  the  diseases  of  children.  But,  if  you  have  not 
cultivated  your  faculties  of  observation,  you  cannot  learn  it,  for  it  is  a 
language  of  signs,  and  these  signs  are  such  as  will  escape  the  notice  of 
the  careless  :  if  you  are  not  fond  of  little  children  you  cannot  learn  it, 
for  they  soon  make  up  their  minds  as  to  who  loves  them,  and  when  ill 
they  will  express  their  real  feelings,  whether  by  words  or  signs,  to  no 
one  else. 

There  is,  moreover,  a  certain  tact  necessary  for  successfully  investi- 
gating the  diseases  of  children.  If,  when  summoned  to  a  sick  child,  you 
enter  the  room  abruptly,  and,  going  at  once  to  your  patient,  you  begin 
to  look  closely  at  it,  while  at  the  same  time  you  question  the  mother  or 
nurse  about  its  ailments  in  your  ordinary  pitch  of  voice,  the  child,  to 
whom  you  are  a  perfect  stranger,  will  be  frightened,  and  will  begin  to 
cry ;  its  pulse  and  respiration  will  be  hurried,  its  face  will  grow  flushed, 
and  you  will  thus  have  lost  the  opportunity  of  acquainting  yourself  with 
its  real  condition  in  many  respects.  Besides  this,  the  child's  alarm,  once 
excited,  will  not  subside  so  long  as  you  are  present :  if  you  want  to  see 
its  tongue,  or  auscultate  its  chest,  its  terrors  will  be  renewed,  and  it  will 
scream  violently  ;  you  will  leave  the  room  little  wiser  than  you  entered 
it,  and,  very  likely,  fully  convinced  that  it  is  impossible  to  make  out 
children's  diseases. 

Very  different  would  be  the  result  if  you  conducted  this  examination 
properly ;  and  though  I  believe,  where  there  is  real  love  for  children, 
the  tact  necessary  for  examining  into  their  ailments  will  not  be  long  in 
being  acquired,  still  a  few  hints  on  this  subject  may  not  be  out  of  place 
in  an  introductory  lecture. 

The  quiet  manner  and  the  gentle  voice  which  all  who  have  been  ill 
know  how  to  value  in  their  attendants,  are  especially  needed  when  the 
patient  is  a  child.  Your  first  object  must  be,  not  to  alarm  it;  if  you 
succeed  in  avoiding  this  danger  it  will  not  be  long  before  you  acquire  its 
confidence.  Do  not,  therefore,  on  entering  the  room,  go  at  once  close 
up  to  the  child,  but,  sitting  down  sufficiently  near  to  watch  it,  and  yet 
so  far  off  as  not  to  attract  its  attention,  put  a  few  questions  to  its 
attendant.  While  doing  this,  you  may,  without  seeming  to  notice  it, 
acquire  great  deal  of  important  information;  you  may  observe  the 
expression  of  the  face,  the  character  of  the  respiration,  whether  slow 
or  frequent,  regular  or  unequal,  and  if  the  child  utter  any  sound  you 
may  attend  to  the  character  of  its  cry.  All  your  observations  must  be 
made  without  staring  the  child  in  the  face ;  little  children,  especially  if 
ill,  seem  always  disturbed  by  this,  and  will  be  almost  sure  to  cry.  If 
the  child  be  asleep  at  the  time  of  your  visit,  your  observations  may  be 
more  minute  :  the  kind  of  sleep  should  be  noticed,  whether  quiet  or  dis- 
turbed, whether  the  eyes  are  perfectly  closed  during  it,  or  partly  open  as 
they  are  in  many  cases  where  the  nervous  system  is  disordered :  you  may, 
too,  if  the  sleep  seem  sound,  venture  to  count  the  frequency  of  the 
respiration,  and  the  beat  of  the  pulse,  but  in  doing  this  you  should  be 
careful  not  to  arouse  the  child.  It  should  be  awakened  gently  by  the 
nurse  or  mother,  and  a  strange  face  should  not  be  the  first  to  meet  its 
eye  on  awaking.     If  it  were  awake  when  you  entered  the  room,  it  will 


20  EXAMINATION   OP   SICK   CHILDREN. 

probably  in  a  few  minutes  have  grown  accustomed  to  your  presence, 
and  will  allow  you  to  touch  its  hand,  and  feel  its  pulse.  This  must 
always  be  done  at  as  early  a  period  in  your  visit  as  possible,  in  order  that 
you  may  count  it  while  the  child  is  undisturbed,  since  the  pulsations  of 
the  heart  vary,  in  young  children,  as  much  as  twenty  in  a  minute  under 
comparatively  slight  disturbing  causes,  and  any  inferences  that  you 
might  draw  from  the  pulse  of  the  child,  when  frightened  or  excited, 
would  almost  certainly  be  erroneous.  Besides  the  pulse,  the  frequency 
of  the  respiration  should,  if  possible,  be  noticed,  since  the  results  ob- 
tained by  a  comparison  of  the  two  are  always  more  valuable  than  those 
of  either  taken  alone.  But  if  this  be  your  first  visit  to  the  child,  do 
not,  for  the  sake  of  ascertaining  either  of  these  points  exactly,  persevere 
in  attempts  which  irritate  or  frighten  it :  probably  you  would,  after  all, 
be  unsuccessful,  and  even  though  you  were  to  succeed,  the  knowledge 
would  not  repay  you  for  the  loss  of  the  child's  confidence,  which  it  must 
be  your  grand  object  to  acquire  and  keep. 

With  management  and  gentleness,  however,  you  will  comparatively 
seldom  fail,  and  while  you  are  feeling  the  pulse,  or  with  the  hand  on  the 
abdomen  are  counting  the  frequency  of  the  inspirations,  you  will  also 
learn  the  temperature  of  the  body  and  the  condition  of  the  skin.  Sup- 
posing your  examination  has  thus  far  been  pretty  well  borne,  you  may 
now,  probably,  venture  to  talk  to  the  child,  or  to  show  it  something  to 
amuse  it — as  your  watch  or  stethoscope,  and  while  thus  testing  the  state 
of  its  mental  powers,  you  may  pass  your  hand  over  the  head,  and  note 
the  state  of  the  fontanelle,  and  the  presence  or  absence  of  heat  of  the 
scalp. 

The  examination  of  the  state  of  the  abdomen,  though  too  important 
to  allow  of  its  ever  being  omitted,  will  often  lead  to  no  satisfactory  result 
unless  carefully  managed.  If  you  allow  the  nurse  to  change  the  child's 
posture  and  to  lay  it  back  in  her  lap,  in  order  that  you  may  pass  your 
hand  over  its  stomach,  the  child  will  often  be  alarmed,  and  begin  to  cry, 
its  abdomen  then  becomes  perfectly  tense,  and  you  cannot  tell  whether 
pressure  on  it  causes  pain,  or  whether  the  cries  are  not  altogether  the 
consequences  of  fear.  It  is  therefore  the  best  plan  to  pass  your  hand 
beneath  the  child's  clothes,  and  to  examine  the  abdomen  without  altering 
its  posture,  while,  at  the  same  time,  the  nurse  talks  to  it  to  distract  its 
attention,  or  holds  it  opposite  the  window  or  a  bright  light,  which 
seldom  fails  to  amuse  an  infant.  If  there  be  no  tenderness  of  the 
abdomen  the  child  will  not  cry  on  pressure,  or  if,  during  your  examina- 
tion, the  presence  of  flatus  in  the  intestines  should  occasion  pain,  gentle 
friction,  instead  of  increasing  suffering,  will  give  relief. 

You  must  next  examine  the  chest :  and  for  this  purpose  immediate 
auscultation  is  always  to  be  preferred,  since  the  pressure  of  the  stetho- 
scope generally  annoys  the  child.  If  the  child  be  not  in  its  bed-gown,  it 
will  usually  be  your  best  course  to  have  the  back  of  its  dress  undone, 
and  then,  while  it  is  seated  on  its  mother's  or  nurse's  lap,  to  kneel 
down  behind  it,  and  apply  your  ear  to  its  chest.  In  all  acute  diseases  of 
the  lungs  in  infancy  the  condition  of  their  posterior  part  is  a  sure  index 
to  the  extent  of  the  mischief  from  which  they  are  suffering ;  for,  owing 
to  the  infant  passing  so  much  of  its  time  in  the  horizontal  position,  the 


EXAMINATION   OF   SICK   CHILDREN.  21 

blood  naturally  gravitates  towards  the  back  of  the  lungs,  and  the  secre- 
tions are  much  more  likely  to  accumulate  in  the  bronchi  in  that  situation 
than  elsewhere  :  hence,  if  air  be  heard  permeating  the  lungs  throughout 
the  whole  posterior  part  of  the  chest,  and  unaccompanied  with  any  con- 
siderable amount  of  crepitation,  it  may  fairly  be  inferred  that  their  front 
parts  are  free  from  serious  disease,  even  though  we  should  be  unable  to 
ascertain  the  fact  by  actual  observation. 

When  you  have  listened  thoroughly  to  the  back  of  the  chest,  you  may 
next  percuss  it.  Your  must  not  percuss  first  and  listen  afterwards,  as 
you  often  do  in  the  adult ;  for  even  when  practised  with  the  greatest 
gentleness,  percussion  sometimes  frets  the  child,  and  makes  it  cry, 
whereby  any  subsequent  attempt  to  listen  to  the  breathing  will  often 
be  rendered  unsuccessful.  But  you  must  not  neglect  percussion  :  it  is 
of  peculiar  value  in  childhood,  since  auscultation  is  then  unavoidably 
incomplete  in  many  instances,  sometimes  quite  impracticable.  In  prac- 
tising it,  however,  there  are  some  rules  without  attention  to  which  you 
will  very  likely  fail  of  acquiring  any  information  whatever.  You  must 
never,  in  the  child,  attempt  to  percuss  the  walls  of  the  chest  immediately, 
but  should  strike  on  your  finger,  and  even  then  very  gently.  The  chest 
of  the  child  is  so  resonant,  that,  if  you  percuss  smartly,  you  will  fail  to 
perceive  the  finer  variations  in  sonoriety  which  would  be  readily  appre- 
ciable on  gentle  percussion.  Always  observe  to  compare  the  results 
obtained  by  percussing  opposite  sides  of  the  chest,  since  otherwise  you 
may  overlook  a  very  considerable  degree  of  dulness.  It  often*  happens, 
too,  that  the  lower  lobes  of  both  lungs  are  involved  nearly  equally ;  you 
must  therefore  notice  the  resonance  of  the  lower  as  compared  with  that 
of  the  upper  part  of  the  chest.  Sometimes  you  are  compelled,  by  the 
fretfulness  of  the  child,  or  by  the  tenderness  of  the  walls  of  its  chest,  to 
percuss  so  gently  as  scarcely  to  elicit  any  sound.  It  is  of  importance, 
therefore,  to  attend  to  the  sensation  of  solidity  communicated  to  the 
finger,  as  well  as  to  the  sound  of  dulness  that  falls  upon  the  ear,  since, 
if  your  sense  of  touch  be  delicate,  it  will  correct  or  confirm  the  evidence 
of  hearing. 

Having  thus  examined  the  back  of  the  chest,  you  may,  if  the  child  be 
likely  to  tolerate  it,  try  to  listen  at  its  sides,  and  then  in  front.  You 
can,  however,  scarcely  auscultate  the  front  of  the  chest  in  infancy  with- 
out a  stethoscope,  and  this  you  will  very  seldom  be  able  to  use  ;  for,  if 
the  child  be  not  frightened,  it  will  probably  be  so  exceedingly  amused 
at  what  it  regards  as  specially  intended  for  its  own  diversion,  that  it 
will  join  in  the  game,  and  disconcert  you  by  playing  with  the  instrument. 
You  will  encounter  this  difficulty  in  cases  of  phthisis  in  early  childhood, 
and  will  often  find  it  no  easy  matter  to  ascertain  the  character  of  the 
respiration  in  the  front  of  the  chest.  In  such  cases  you  will  learn  all 
the  value  of  percussion,  which  may  be  practised  over  the  front  of  the 
chest  as  well  as  the  back,  while  the  state  of  the  breathing  in  the  upper 
and  back  part  of  the  chest  will  generally  be  a  correct  index  to  its  con- 
dition in  front. 

Your  examination  of  the  chest  will  not  be  complete  until  you  have 
noticed  the  general  character  of  the  breathing,  whether  the  whole  of  the 
chest  is  expanded  by  it,  or  whether  the  respiration  is  merely  abdominal 


22  CASE-TAKING. 

— whether-the  child  breathes  as  deeply  as  it  should,  or  whether  it  makes 
frequent  short  inspirations  which  cannot  fill  the  smaller  bronchi.  The 
time  for  ascertaining  these  points  must  vary  in  each  case ;  but  the 
earlier  they  are  observed  the  better,  since  otherwise  you  run  the  risk 
of  drawing  your  inferences  not  from  the  child's  ordinary  condition,  but 
from  its  condition  when  excited  and  alarmed.  Some  of  these  points  may 
be  noticed  though  the  child  be  so  fretful  that  you  cannot  auscultate  even 
the  back  of  its  chest  satisfactorily.  An  imperfect  auscultation,  however, 
is  better  than  none  ;  for  at  the  very  worst,  during  the  deep  inspirations 
that  are  made  at  intervals  in  a  fit  of  crying,  you  may  ascertain  how  far 
the  lungs  are  permeable  to  air,  and  whether  the  bronchi  are  much  loaded 
with  mucus.  Independently  of*  auscultation,  too,  much  may  be  learned 
from  the  cry.  If  its  two  periods  be  clearly  marked — the  long  loud  cry 
of  expiration,  and  the  shorter,  less  loud,  but  perfectly  distinct  sound 
that  attends  inspiration — you  may  feel  convinced  that  there  exists  no 
important  ailment  of  the  respiratory  organs. 

It  will  still  remain  for  you  to  examine  the  tongue,  and  to  ascertain 
the  condition  of  the  gums ;  and  it  is  wise  to  defer  this  to  the  last,  since 
it  is  usually  the  most  grievous  part  of  your  visit  to  the  child.  If  during 
any  part  of  your  previous  examination  it  had  cried,  you  might  seize  that 
opportunity  to  look  at  its  tongue,  and,  if  necessary,  to  pass  your  finger 
over  the  gums,  thus  sparing  it  any  further  distress  about  the  matter. 
If  you  had  not  this  opportunity,  you  will  generally  get  a  good  view  of 
the.  mouth  and  throat  in  young  infants  by  gently  touching  the  lips  with 
your  finger ;  the  child  opens  its  mouth  instinctively,  and  then  you  can 
run  your  finger  quickly  over  its  tongue,  and  down  towards  the  pharynx, 
and  thus  secure  a  perfect  view  of  the  mouth  and  throat.  With  older 
children  a  good  deal  of  coaxing  is  sometimes  necessary  to  persuade  them 
to  open  their  mouth :  but,  if  once  you  get  your  finger  on  the  gum,  you 
can  usually  keep  them  quiet  by  rubbing  it,  and  by  a  little  address  will 
then  seldom  fail  in  opening  the  mouth  wide  enough  to  get  a  view  of 
the  tongue. 

If  little  children  be  very  ill,  all  this  minute  care  in  the  order  of  your 
examination  is  not  so  much  needed,  because  they  will  not  notice  so 
quickly  ;  but  gentleness  of  tone  and  manner  will  be  even  more  necessary 
to  soothe  the  pettishness  and  quiet  the  alarm  of  the  little  sufferer. 

Many  of  the  directions  that  I  have  just  given  you  refer  to  the  exami- 
nation of  infants,  and  become  less  applicable  in  proportion  to  the  greater 
age  of  the  patient.  Minute  rules  for  your  examination  of  children  from 
three  years  old  and  upwards  are  not  needed ;  but  patience  the  most 
untiring,  and  good  temper  the  most  unruffled,  are  indispensable. 

The  previous  history  of  a  patient,  the  circumstances  under  which  his 
present  illness  came  on,  and  the  symptoms  that  at  first  attended  it, 
often  help  to  remove  our  doubts  with  reference  to  the  nature  of  a  disease, 
and  sometimes  greatly  modify  our  diagnosis  and  influence  our  plan  of 
treatment.  Really  trustworthy  information  on  these  points,  however,  is 
often  difficult  to  be  obtained,  and  the  attempt  to  elicit  it  is  almost  sure 
to  be  unsuccessful,  if  the  questions  put  to  the  patient  are  proposed  at 
random,  and  without  some  previously  well-digested  plan  on  the  part  of 
the  physician.     One  great  object  of  clinical  instruction  is  to  teach  the 


CASE-TAKING.  23 

student  so  to  conduct  this  as  well  as  other  parts  of  his  examination  of 
the  sick,  as  to  throw  from  every  source  the  greatest  possible  amount  of 
light  upon  the  nature  of  the  disease,  and  thus  to  fit  himself  to  decide 
with  some  approach  to  certainty  on  the  means  most  likely  to  effect  its 
cure.  Such  instruction  has  been  amply  afforded  you  in  the  wards  of 
this  hospital ;  but  you  must  allow  me  to  detain  you  while  I  point  out 
the  subjects  towards  which  your  inquiries  must  be  especially  directed  in 
the  case  of  children,  since  they  differ  in  many  respects  from  the  questions 
that  you  would  propose  if  your  patient  were  an  adult. 

We  will  suppose,  if  you  please,  that  a  child  is  brought  to  you  of  whose 
case  you  wish  to  preserve  a  record.  Its  name,  age,  sex,  and  resi- 
dence will  form  of  course  the  first  entry  in  your  note-book ;  but  your 
next  inquiries  should  be  as  to  the  number  of  living  children  that  the 
parents  have  had,  whether  any  of  those  children  have  died,  and,  if  so,  at 
what  age,  and  of  what  diseases,  and  as  to  the  health  of  both  parents, 
and  of  their  immediate  relatives.  The  object  of  these  questions  is  to 
ascertain  whether  there  exists  any  hereditary  tendency  to  disease  in  the 
family,  since  that  plays  a  most  important  part  in  many  of  the  affections 
of  childhood,  and  symptoms  that  in  the  child  of  healthy  parents  would 
cause  you  but  little  uneasiness,  would  at  once  excite  serious  alarm  if 
you  knew  that  some  members  of  the  family  had  died  of  hydrocephalus, 
or  consumption,  or  had  been  the  subjects  of  scrofula. 

Many  of  the  most  serious  affections  of  childhood  occur  within  the 
period  of  a  few  years,  and  after  a  certain  age  are  comparatively  rare  in 
their  occurrence,  and  generally  mild  in  their  character.  It  is  therefore 
very  desirable,  when  any  ailment  is  coming  on  the  nature  of  which  is  not 
yet  quite  apparent,  to  know  which  of  the  diseases  incidental  to  childhood 
have  already  affected  your  patient.  With  this  view  you  would  ask 
wThether  the  child  has  been  vaccinated,  or  has  had  the  small-pox,  and 
whether  it  has  passed  through  any  other  of  those  affections — such  as 
chicken-pox,  hooping-cough,  measles,  or  scarlatina,  which  generally  come 
on  in  early  life.  If  the  child  had  suffered  from  any  other  disease,  you 
should  learn  its  nature,  the  age  at  which  it  occurred,  and  any  other  point 
of  importance  connected  with  it. 

In  writing  out  our  history  of  the  case,  these  preliminary  matters 
would  naturally  be  mentioned  at  the  beginning,  and  though  you  would 
not  follow  any  very  strict  order  in  proposing  your  questions,  yet  it  is 
always  desirable  to  obtain  information  on  these  points  at  an  early  stage 
of  your  examination,  since  it  may  guide  you  in  some  of  the  questions  that 
you  afterwards  propose,  or  may  lead  you  to  pay  particular  attention  to 
symptoms  which  otherwise  would  not  seem  to  be  of  much  moment. 
Besides,  if  you  postpone  these  inquiries  till  you  have  nearly  completed 
your  examination  of  the  patient,  the  parents  will  probably  apprehend  that 
they  are  suggested  by  some  doubt  and  apprehension  in  your  mind  as  to 
the  nature  of  the  case,  and  will  distress  themselves  by  causeless  fears, 
or  perhaps  disconcert  you  by  questions  to  which  you  are  not  prepared 
to  return  a  positive  answer. 

There  are  two  other  points  which  bear  on- the  general  condition  of  the 
child,  to  one  or  both  of  which  your  inquiries  must  in  many  instances  be 
directed.     If  your  patient  be  an  infant  at  the  breast,  you  must  learn 


24  CASE-TAKING. 

■whether  it  lives  entirely  on  its  mother's  milk,  or  has  other  food  besides. 
If  it  has  been  weaned,  you  must  ask  its  age  at  weaning — whether  it  was 
taken  from  the  breast  on  account  of  any  failure  in  its  own  health,  or  its 
mother's,  and  on  what  diet  it  has  since  been  fed.     The  process  of  den- 
tition is  the  other  subject  for  inquiry ;  and  in  reference  to  it,  you  must 
ascertain  how  many  teeth  the  child  has,  and  which  they  are — whether 
they  were  cut  easily  or  with  difficulty,  the  age  at  which  teething  com- 
menced, and  the  time  that  has  elapsed  since  any  fresh  teeth  appeared. 
You  may  now  endeavour  to  obtain  a  clear  and  connected  history  of 
the  present  illness ;  and  for  this  purpose  it  is  well  to  begin  with  asking 
when  did  the  child  last   seem  quite  well  ?    since  you  thus  get  a  fixed 
starting  point  from  which  you  can  make  the  mother  or  nurse  set  out  in 
her  detail  of  symptoms.     The  date  thus  assigned,  indeed,  will  often  be 
a  wrong  one,  the  disease  having  begun  before  with  some  symptom  that 
was  not  noticed,  or  its  real  origin  having  been  considerably  subsequent 
to  its  supposed  commencement.      But  notwithstanding  this  possible 
error,  you  derive  much  advantage  from  thus  making  sure  of  the  symp- 
toms being  told  you  in  something  like  their  chronological  order,  since 
otherwise  it  is  very  likely  that  those  only  would  be  mentioned  which 
had  chanced  to  strike  the  mind  of  the  mother  or  nurse,  while  the  others 
would  be  passed  over  in  silence.     Your  object  in  the  examination  must' 
not  be  to  curtail  the  garrulity  of  the  nurse,  or  to  suppress  the  mother's 
expression  of  her  sometimes  imaginary  fears,  but  to  get  as  clear  an 
account  as  possible  of  everything  that  has  been  observed.     You  must 
be  careful  not  to  underrate  the  value  of  the  information  they  communi- 
cate, or  even  of  the  opinions  they  express.     Both  are  much  more  likely 
to  be  correct  when  your  patients  are  children,  than  when  they  are 
adults.     A  mother  hanging  over  her  sick  infant,  or  a  nurse  watching 
the  child  she  has  helped  to  rear  from  babyhood,  may  sometimes  see 
dangers  that  have  no  existence,  but  will  generally  be  the  first  to  per- 
ceive the  approach  of  such  as  are  real.     You  see  the  child  but  for  a 
few  minutes,  and  at  distant  intervals,  and  the   excitement  or  alarm 
which  your  presence  is  so  likely  to  occasion  may  greatly  modify  its 
condition  during  your  visit.     They  tend  the  little  one  by  day  and 
night,  notice  each  movement,  and  seize  the  most  transient  variations 
in  its  expression. 

I  need  not  say  much  concerning  the  necessity  of  inquiring  about  the 
appetite  and  thirst,  the  state  of  the  bowels,  and  the  appearance  of  the 
evacuations ;  for  these  are  points  which  you  would  investigate  in 
patients  of  every  age.  I  will  just  mention,  however,  that  the  degree 
of  appetite  and  thirst  cannot  be  so  readily  determined  in  the  infant  as 
they  may  be  in  the  adult,  or  even  in  the  weaned  child ;  for  an  infant 
may  suck,  not  because  it  is  hungry,  but  in  order  to  quench  its  thirst. 
That  extreme  craving  for  the  breast,  which  is  appeased  only  so  long  as 
the  child  is  sucking,  while  the  milk  swallowed  is  speedily  vomited,  may 
be  taken  as  a  sign  of  thirst ;  but  it  is  always  better  to  record  the  fact 
than  the  inference,  It  is  likewise  often  desirable  to  let  the  infant  be 
put  to  the  breast  in  your  presence,  not  only  for  the  sake  of  observing 
the  above-mentioned  facts,  but  also  in  order  to  notice  the  vigour  with 
which  it  sucks,  the  ease  or  difficulty  with  which  it  swallows,  and  other 


CASE-TAKING — PLAN   OF   THE   COURSE.  25 

similar  points  from  which  very  important  conclusions  may  often  be 
drawn. 

Before  you  venture  on  drawing  any  inferences  from  the  state  of  the 
child  at  the  time  of  your  visit,  you  should  ascertain  whether  it  has  just 
before  been  taking  food,  or  has  been  recently  excited  or  fatigued  by 
being  washed  or  dressed ;  since  comparatively  trivial  causes  are  suffi- 
cient to  accelerate  the  pulse  and  respiration,  and  to  give  rise  to  changes 
which  might,  if  unexplained,  lead  you  to  very  erroneous  conclusions. 
Any  such  circumstances  ought  of  course  to  be  mentioned  in  your  notes, 
as  should  also  the  fact  of  the  child  being  asleep  at  the  time  of  your 
visit,  since  that  would  explain  even  a  very  considerable  diminution  in 
the  frequency  of  the  pulse  and  respiration. 

But  if  you  are  carefully  to  observe  all  the  points  which  I  have  men- 
tioned, and  to  make  yourselves  thoroughly  masters  of  a  case,  you  must 
be  most  lavish  of  your  time ;  you  must  be  content  to  turn  aside  from 
the  direct  course  of  investigation,  which  you  would  pursue  uninter- 
ruptedly in  the  adult,  in  order  to  soothe  the  waywardness  of  the  child, 
to  quiet  its  fear,  or  even  to  cheat  it  into  good  humour  by  joining  in  its 
play  ;  and  you  must  be  ready  to  do  this,  not  the  first  time  only,  but 
every  time  that  you  visit  the  child,  and  must  try  to  win  its  affections 
in  order  to  cure  its  disease.  If  you  fail  in  the  former,  you  will  often 
be  foiled  in  your  attempts  at  the  latter.  Nor  is  this  all :  you  must 
visit  your  patient  very  often,  if  the  disease  be  serious  in  its  nature  and 
rapid  in  its  course.  New  symptoms  succeed  each  other  in  infancy  and 
childhood  with  great  rapidity ;  complications  occur  that  call  for  some 
change  in  your  treatment,  or  the  vital  powers  falter  suddenly,  when 
you  least  expect  it.  The  issues  of  life  and  death  often  hang  on  the 
immediate  adoption  of  a  certain  plan  of  treatment,  or  its  timely  discon- 
tinuance. Do  not  wait,  therefore,  for  symptoms  of  great  urgency 
before  you  visit  a  child  three  or  four  times  a  day,  but  if  the  disease  be 
one  in  which  changes  are  likely  to  take  place  rapidly,  be  frequent  in 
your  visits  as  well  as  watchful  in  your  observation. 

You  will  naturally  think,  that  before  I  finish  this  lecture  I  should 
tell  you  something  definite  about  the  subjects  that  I  mean  to  bring 
before  your  notice,  and  the  manner  in  which  I  propose  to  treat  them. 
The  title  of  these  lectures  can,  I  should  think,  scarcely  need  any 
explanation,  for  by  the  diseases  of  infancy  and  childhood  you  will 
naturally  understand  all  those  affections  which  are  either  limited  in 
the  time  of  their  occurrence  to  early  life,  or  which,  though  incidental 
to  all  ages,  yet  in  the  child  present  many  peculiarities  in  their  symp- 
toms, and  require  many  important  modifications  in  their  treatment. 
Some  of  these  diseases,  indeed,  are  usually  allotted  to  the  care  of  the 
surgeon,  and  on  their  examination  I  will  not  enter,  since  I  could  tell 
you  nothing  more  than  has  already  been  better  said  by  others.  They, 
however,  are  but  few  in  number,  and  most  of  them  are  purely  local 
affections,  so  that  these  omissions  will  not  be  many,  and  most  of  them 
not  important. 

In  the  description  of  the  diseases  of  children,  no  practically  useful 
end  would  be  attained  by  following  any  elaborate  nosological  system. 
I  shall  therefore  adopt  the  most  simple  classification  possible,  and  shall 


26    "  FREQUENCY   OF   DISEASES   OF   THE   NERVOUS   SYSTEM. 

treat  in  succession  of  the  diseases  of  the  nervous  system,  of  the  respi- 
ratory and  circulatory,  and  of  the  digestive  systems  and  their 
appendages.  There  will  still  remain  one  very  important  class  of 
affections,  namely,  fevers  ;  and  these  I  propose  to  consider  last  of  all, 
because  much  of  their  danger  arises  from  their  complications,  and  to 
treat  them  judiciously  you  must  be  familiar  with  the  diseases  of  the 
brain,  the  lungs,  and  the  bowels.  In  this  plan  it  will  be  easy  to  detect 
a  want,  perhaps  too  great  a  want,  of  scientific  arrangement,  but  the 
one  object  of  my  endeavours  will  be  to  communicate  to  you,  as  clearly 
as  I  can,  such  information  as  may  be  most  useful  to  you  in  the  dis- 
charge of  your  daily  duties. 

With  this  view,  I  have,  while  composing  these  lectures,  tried  to 
think  over  the  doubts  I  felt,  the  difficulties  I  met  with,  and  the  errors 
I  fell  into,  when,  some  years  ago,  I  entered  on  the  office  of  physician 
to  a  large  institution  for  the  cure  of  children's  diseases.  I  have  pre- 
sumed that  where  I  had  encountered  difficulties  there  you  might  meet 
them  too, — that  where  I  had  made  mistakes  there  you  would  need  a 
guide, — and  remembering  the  many  anxious  hours  I  passed  when  I 
hesitatingly  adopted  some  course  of  treatment  which  I  feared  might 
after  all  be  a  mistaken  one,  it  has  been  my  endeavour  to  lay  down,  not 
only  the  rules  for  the  diagnosis,  but  also  the  indications  for  the  treat- 
ment of  each  disease  as  minutely  as  possible. 

To  the  task  before  me  I  now  apply  myself,  with  a  deep  conviction 
of  the  narrow  limits  of  my  own  knowledge,  but  still  feeling  that  I'have 
contracted  an  obligation  to  impart  to  others  what  I  trust  experience 
has  taught  me.  My  end  will  be  answered,  if  you  learn  it  at  an  easier 
rate  than  I  did;  and  if  I  can  be  the  means  of  saving  you  from  some  of 
those  errors  in  diagnosis,  and  same  of  those  mistakes  in  treatment, 
which,  for  want  of  some  one  to  guide  me  aright,  I  committed. 


LECTURE    II. 

Diseases  op  the  Brain  and  Nervous  System. — Their  extreme  frequency  in  early  life 
favoured  by  the  rapid  development  of  the  brain,  and  the  wide  variations  in  the  cere- 
bral circulation  during  childhood. — Peculiar  difficulties  of  their  study. — Symptoms  of 
cerebral  disease  in  the  child. — Convulsions,  their  frequency  in  great  measure  due  to 
the  predominance  of  the  spinal  system  in  childhood — may  be  excited  by  many  causes — 
hence  attention  should  always  be  paid  to  the  precursors  of  an  attack.  Description  of 
a  fit  of  convulsions. 

It  can  scarcely  be  necessary  to  assign  many  reasons  for  beginning 
this  course  of  lectures  with  the  study  of  the  diseases  of  the  nervous 
system.  The  subject,  although  beset  with  many  difficulties,  has  always 
engaged  mnch  attention  ;  partly,  no  doubt,  from  the  natural  tendency 
of  the  human  mind  to  inquire  most  curiously  into  those  truths  that 
seem  most  hidden ;  but  still  more  from  the  alarming  nature  of  many  of 
the  symptoms  that  betoken  disturbance  of  the  nervous  system,  and 
from  the  frequently  fatal  issue  of  its  diseases.     But  besides  the  general 


FREQUENCY  OF  DISEASES   OF   THE   NERVOUS   SYSTEM.  27 

interest  and  importance  of  these  affections,  at  whatever  age  they  may 
occur,  their  extreme  frequency  in  early  life  gives  them  an  additional 
claim  on  our  notice. 

It  appears  from  the  Reports  of  the  Registrar-General,  that  16,258 
out  of  91,225  persons  who  died  in  the  metropolis  during  the  years  1842 
and  1815,  of  ascertained  causes,  were  destroyed  by  the  various  diseases 
of  the  nervous  system.  But  9,350  of  these  16,258  deaths  took  place 
during  the  first  five  years  of  existence ;  or  in  other  words,  57  per  cent. 
of  the  fatal  disorders  of  the  nervous  system  occurred  within  that 
period.1  Even  after  making  a  very  large  allowance  for  the  possible 
errors  of  statistical  data,  this  predominance  of  the  diseases  of  the 
nervous  system  in  early  life  is  far  too  remarkable  to  be  overlooked ; 
though  some  persons,  not  being  able  to  account  for  the  fact,  have 
affected  to  doubt  its  reality. 

The  fact  is  one  which  cannot  be  gainsaid  ;  and  though  we  cannot 
pretend  thoroughly  to  account  for  it,  yet  two  considerations  may  help 
in  some  degree  to  explain  it. 

The  first  is  derived  from  our  knowledge  of  the  circumstance,  that 
in  an  organ  whose  development  is  rapidly  advancing,  many  diseased 
processes  also,  if  once  set  up,  will  go  on  with  proportionate  activity. 
Now  there  is  no  organ  in  the  body,  with  the  exception  of  the  pregnant 
womb,  which  undergoes  such  rapid  development  as  the  brain  in  early 
childhood.  It  doubles  its  weight  during  the  first  two  years  of  life, 
and  reaches  nearly,  if  not  quite,  its  maximum  by  the  end  of  the 
seventh  year.  This  same  active  state  of  the  nutritive  or  vegetative 
processes  in  the  brain  of  the  child  renders  the  organ  liable  to  have 
disease  set  up  in  it  by  causes  which  would  produce  little  or  no 
injurious  effect  on  the  brain  of  the  adult. 

In  the  second  place,  the  brain  in  infancy  is  much  more  exposed  to 
disorder  than  that  of  the  adult,  owing  to  the  far  wider  variations  of 
which  the  cerebral  circulation  is  susceptible  in  early  life  than  subse- 
quently. Nor  is  the  cause  of  this  difficult  to  discover.  The  cranium 
of  the  adult  is  a  complete  bony  case,  and  the  firm  substance  of  the 
brain  affords  a  comparatively  unyielding  support  to  the  vessels  by 
which  it  is  nourished.  It  has  been  proved,  indeed,  by  Dr.  Burrows2 
that  the  quantity  of  blood  which  these  vessels  contain  is  not  always 
the  same,  as  some  have  erroneously  supposed :  still  its  variations  must 
needs  be  circumscribed  within  far  narrower  limits  than  in  the  child, 
whose  cranium,  with  its  membranous  fontanelles  and  unossified  sutures, 

1  These  numbers,  -which  yield  results  differing  but  very  little  from  those  given  in  the 
former  edition,  are  deduced  from  the  returns  given  in  the  Fifth  and  Eighth  Reports. 
The  returns  for  184G,  which  are  also  given  in  the  Eighth  Report,  are  not  included, 
since,  owing  to  the  epidemic  prevalence  of  diarrhoea  in  the  autumn  of  1846,  they  would 
not  yield  average  results. 

2  In  his  Lumleian  Lectures,  published  in  the  Medical  Gazette,  April  28,  and  May  6, 
1843,  and  subsequently  in  his  work  on  Disorders  of  the  Cerebral  Circulation,  &c.  8vo. 
Lond.  1846.  The  general  accuracy  of  Dr.  Burrows'  conclusions,  though  called  in  question 
by  the  late  Dr.  John  Reid,  in  the  London  and  Edinburgh  Monthly  Journal  for  Aug. 
1846  ;  and  more  recently  by  Dr.  Hamernjk,  of  Prague,  in  the  Vierteljahrschrift,  fur  die 
praktische  Heilkunde,  Vol.  xvii.  p.  38,  seems  to  be  placed  beyond  doubt  by  the  very 
careful  experiments  of  Dr.  Berlin,  published  in  the  Nederlandsche  Lancet,  Feb.  1850; 
and  in  Schmidt's  Jahrbucher  for  1851,  No.  1,  p.  14 — 15. 


28  SYMPTOMS   OF   CEREBRAL   DISEASE. 

opposes  no  such  obstacle  to  the  admission  of  an  increased  quantity  of 
blood,  while  the  soft  brain  keeps  up  a  much  slighter  counter-pressure 
on  the  vessels  than  is  exerted  by  the  comparatively  firm  parenchyma 
of  the  organ  in  the  adult.  If  the  circulation  in  the  child  be  disturbed, 
whether  from  difficulty  in  the  return  of  venous  blood,  as  during  a 
paroxysm  of  hooping-cough  or  from  increased  arterial  action,  as  at  the 
onset  of  a  fever,  or  during  the  acute  inflammation  of  some  important 
organ,  the  brain  becomes  congested,  and  convulsions  often  announce 
the  severity  of  the  consequent  disturbance  of  its  functions.  The  same 
causes,  too,  which  expose  the  brain  to  be  overfilled  with  blood,  render  it 
possible  for  it  to  be  drained  of  its  blood  more  completely  than  in  the 
adult.  This  fact,  which  you  should  always  bear  in  mind  when 
treating  the  diseases  of  infants,  is  one  reason  why  excessive  depletion 
induces  a  far  more  serious  train  of  symptoms  in  young  children  than 
succeed  to  it  in  the  grown  person. 

It  happens,  unfortunately,  that  while  there  are  special  reasons  for 
studying  the  diseases  of  the  nervous  system  in  childhood,  their  study  is 
beset  with  special  difficulties  which  we  do  not  meet  with  in  the  adult. 
Disordered  intellect,  altered  sensation,  impaired  motion,  are  the  three 
great  classes  to  which  the  symptoms  of  disease  of  the  nervous  system 
may  be  referred.  If  our  patient  be  an  adult,  he  tells  us  of  his  altered 
feelings  ;  he  perhaps  experiences  some  disorder  of  his  intellectual 
powers  even  before  it  has  become  observable  to  others,  and,  thus  timely 
wrarned,  we  can  often  take  measures  to  prevent  the  advance  of  disease 
and  to  ward  off  that  impairment  of  the  motor  powers  which  in  his  case 
we  know  usually  indicates  the  occurrence  of  some  grave  organic  lesion. 
In  the  child  things  follow  a  very  different  course.  At  first  it  cannot 
express  its  sensations  at  all,  while,  long  after  it  has  acquired  the  power 
of  speech,  it  knows  too  little  how  to  shape  its  ideas  into  words  to  give 
a  correct  account  of  what  it  feels  ;  and  we  cannot  expect  to  learn  much 
from  the  disturbances  of  an  intellect  which  as  yet  has  scarcely  asserted 
its  claim  to  be  any  higher  than  the  instinct  of  the  animal.  The  value 
of  the  symptoms,  too,  is  different ;  for  disturbance  of  the  motor  power, 
which  is  comparatively  rare  in  the  adult,  except  as  the  consequence  of 
some  serious  disease  of  the  brain,  takes  place  in  the  child  in  cases  of 
the  mildest  as  well  as  of  the  most  serious  ailments  ;  and  we  may  even 
observe  convulsions  recurring  several  times  a  day  for  many  days 
together,  apparently  without  adequate  cause,  and  not  leading  to  any 
serious  impairment  of  the  child's  health. 

How,  then,  are  we  to  attain  in  the  child  to  anything  beyond  the 
merest  guess-work  in  our  diagnosis  of  diseases  of  the  nervous  system, 
when  we  are  deprived  to  so  great  an  extent  of  that  information  which 
the  state  of  his  intellect  and  the  description  of  his  sensations  afford  us 
in  the  adult  ?  What  meaning  are  we  to  attach  to  that  symptom — the 
impairment  of  the  motor  power,  which  in  the  adult  we  look  on  as  of 
such  grave  import,  but  which  we  meet  with  in  the  child  under  such 
varying  conditions  and  in  by  far  the  greater  number  of  cases  ?  The 
task,  indeed,  is  attended  with  difficulty,  and  the  solution  of  these 
inquiries  will  need  that  you  should  devote  to  it  some  time  and  some 
careful  observation ;  but  if  you  do  thi  syou  need  not  despair  of  learning 


CONVULSIONS.  29 

much  about  an  infant's  sensations,  and  the  state  of  its  mind,  and  will 
at  length  become  able  rightly  to  interpret  the  meaning  even  of  a  fit  of 
convulsions. 

It  may  be  well  to  pause  here  for  a  moment,  and  briefly  to  pass  in 
review  the  symptoms  by  which  disease  of  the  nervous  centres,  and 
especially  of  the  brain,  manifests  itself  in  infancy  and  early  childhood. 

The  painful  sensations  which  the  infant  experiences  soon  show  them- 
selves in  the  haggard,  anxious,  or  oppressed  look,  which  takes  the  place 
of  the  naturally  tranquil  expression  of  its  countenance.  It  often  puts 
its  hand  to  its  head,  or  beats  or  rubs  it,  or,  while  lying  in  its  cot,  bores 
with  its  occiput  in  its  pillow,  owing  to  which,  in  children  who  have 
suffered  for  any  time  from  uneasy  sensations  in  the  head,  you  will  often 
find  the  hair  worn  quite  off  the  occiput.  It  turns  its  head  away  from 
the  light,  and  lies  much  with  its  eyes  half  closed,  in  a  state  of  apparent 
drowsiness,  from  which  it  often  arouses  with  a  start,  and  cries.  The 
cry,  especially  in  inflammatory  disease,  is  peculiar ;  it  is  generally  a 
low,  almost  constant  moan,  very  sad  to  hear, — interrupted  occasionally 
by  a  sharp,  piercing,  lamentable  cry,  almost  a  shriek.  If  the  child  be 
young  it  will  often  seem  relieved  by  being  carried  about  in  its  nurse's 
arms, -and  while  she  is  moving  will  cease  its  wail  for  a  time,  but  begin 
it  again  the  moment  she  stands  still.  You  will  sometimes  observe,  too, 
that  if  moved  from  one  person's  arms  to  those  of  another,  or  even  if  its 
position  be  but  slightly  altered,  a  sudden  expression  of  alarm  will  pass 
across  its  features ;  the  child  is  dizzy,  and  afraid  of  falling. 

You  see,  then,  that  even  in  the  infant  there  is  a  language  of  signs 
by  which  we  learn  with  certainty  the  existence  of  pain  in  the  head,  and 
the  connexion  of  this  pain  with  dizziness  and  intolerance  of  light.  You 
must  beware,  however,  of  concluding  from  any  one  set  of  symptoms 
that  the  head  is  the  seat  of  real  disease.  The  child,  as  well  as  the 
adult,  may  have  sick  headache,  and  the  degree  of  febrile  disturbance, 
of  heat  of  surface,  and  of  heat  of  head,  together  with  the  state  of  the 
digestive  organs,  are  all  to  be  taken  into  account  in  forming  your 
diagnosis. 

Something  may  be  learned  of  the  state  of  the  mental  powers  and  of 
the  feelings  even  in  early  infancy.  Have  you  never  watched  an  infant 
on  its  mother's  lap,  and  noticed  the  look  of  happy  recognition  with 
which  its  eye  meets  that  of  its  mother  ?  An  early  result  of  cerebral 
disease  is  to  interrupt  this  intercourse  :  the  child  now  never  seems  to 
catch  its  mother's  eye,  but  lies  sad  and  listless,  as  if  all  persons  were 
alike  indifferent  to  it ;  or  at  other  times  even  familiar  faces  cause  alarm, 
the  child  apparently  not  recognizing  those  who  yet  have  always'tended 
it.  This  disturbance,  however,  is  but  momentary,  and  the  child  sub- 
sides into  its  former  condition,  and  allows  itself  to  be  taken  by  those 
at  whom  a  minute  before  it  seemed  frightened. 

But  these  symptoms  are  to  be  interpreted  by  the  light  thrown  on 
them  from  other  sources,  and  by  the  information,  both  positive  and 
negative,  thus  obtained.  You  fear  that  disease  is  going  on  in  the 
brain  ;  but  is  the  skin  hot  ? — is  there  heat  of  head  ? — are  there  fre- 
quent flushings  of  the  face,  and  does  the  accession  of  each  flush  seem 
connected  with  an  increase  of  agitation  and  distress,  or  followed  by  a 


30  CONVULSIONS. 

deepening  of  the  drowsiness  ?  Is  the  fontanelle  prominent  and  tense, 
or  are  the  pulsations  of  the  brain  to  be  felt  with  unusual  force  through 
it? — are  the  veins  of  the  scalp  full,  or  do  the  carotids  beat  with 
unusual  force  ?  What  is  the  character  of  the  pulse  ? — is  it  not  merely 
increased  in  rapidity  ;  but  even  when  examined  under  exactly  similar 
conditions,  does  it  afford  a  different  result  each  time  ?  Do  you  find  it 
irregular  in  frequency,  or  unequal  in  the  force  of  its  beats,  or  even 
distinctly  intermittent  ?  Again,  what  is  the  state  of  the  pupil  ? — is  it 
generally  contracted,  as  if  to  exclude  light  as  much  as  possible  from 
the  over-sensitive  retina  ?  or  is  it  usually  dilated,  and  does  it  act  slowly, 
as  though  disease  had  deadened  the  sensibility  of  the  nervous  system  ; 
or  do  the  pupils  of  the  two  eyes  not  act  simultaneously,  but  one  more 
readily  than  the  other  ?  Do  the  pupils  oscillate  under  the  light ;  at 
first  contracting,  then  dilating,  and  either  remaining  dilated  or  con- 
tinuing to  oscillate,  though  within  narrower  limits,  and  with  a  tendency 
to  remain  more  dilated  than  at  first  ?  Or,  lastly,  do  you  find,  when 
the  child  is  roused,  this  oscillation  of  the  pupil  going  on  under  the 
ordinary  amount  of  light  that  enters  the  chamber  ?  Now  all  of  these 
are  indications  of  disordered  function  of  the  brain,  and  many  of  them 
point  to  disorder  of  a  very  serious  kind. 

But  there  are  yet  other  sources  from  which  we  must  not  neglect  to 
seek  for  information.  Much  may  be  learned  from  the  state  of  the 
digestive  functions.  The  bowels  are  almost  always  disturbed ;  usually, 
though  not  invariably,  constipated,  while  nausea  and  vomiting  are 
seldom  absent.  I  am  not  acquainted  with  any  one  symptom  which 
should  so  immediately  direct  your  attention  to  the  brain,  as  the  occur- 
rence of  causeless  vomiting,  and  especially  its  continuance.  At  first, 
perhaps,  the  child  vomits  only  when  it  has  taken  food  ;  but  before  long 
the  stomach  will  reject  even  the  blandest  fluid,  and  then  the  efforts  at 
vomiting  will  come  on  when  the  stomach  is  empty,  a  little  greenish 
mucus  being  rejected,  with  no  relief,  the  retching  and  vomiting  soon 
returning.  I  shall  have  occasion  to  dwell  again  upon  the  importance 
of  this  symptom,  which  I  have  known  continue  for  several  days  before 
any  other  indication  of  cerebral  disease  could  be  discovered.  In 
children  of  three  or  four  years  old  this  occurrence  would  scarcely  be 
overlooked ;  but  the  case  is  different  with  infants,  who  so  often  vomit 
the  milk  when  ill,  that  the  mother  or  nurse  might  fail  to  mention  it  to 
you  if  you  did  not  make  special  inquiries  with  reference  to  that  point. 

,The  manner  in  which  the  functions  of  the  respiratory  organs  are 
performed  is  also  not  to  be  overlooked.  That  peculiar,  unequal, 
irregular  breathing,  to  which  the  name  of  cerebral  respiration  has 
been  applied,  though  of  considerable  value  when  present,  is  sometimes 
not  observed,  or  not  until  the  disease  of  the  brain  is  already  so  far 
advanced  that  all  questions  of  diagnosis  have  long  been  set  at  rest. 
There  is,  moreover,  a  short,  hard,  hacking  cough,  which  you  may  some- 
times hear,  and  the  import  of  which  you  ought  to  be  acquainted  with, 
since  it  betokens  disease  of  the  brain,  ^not  of  the  lungs.  There  are 
peculiar  sounds,  too,  which  sometimes  attend  respiration,  and  are 
known  as  indicating  disturbance  of  the  nervous  system.  To  these, 
however,  I  shall  have  to  return  hereafter,  since  they  betoken  a  disease 


CONVULSIONS — DUE   TO   PREDOMINANCE   OP   THE   SPINAL   SYSTEM.        31 

of  a  serious  nature,  known  by  the  name  of  spasmodic  croup,  and  which 
I  must  in  the  course  of  these  lectures  describe  in  full. 

I  have  purposely  delayed  till  now  speaking  of  the  indications  of  cere- 
bral disease  afforded  by  the  occurrence  of  convulsions.  The  symptom  is 
one  undoubtedly  of  great  importance,  since  it  is  observed  in  almost 
every  case  of  serious  disease  of  the  brain,  at  some  stage  or  other  of  its 
progress.  The  very  frequency  of  the  phenomenon,  however,  and  the 
great  variety  of  the  circumstances  under  which  it  occurs,  render  it  diffi- 
cult for  us  rightly  to  interpret  its  meaning.  Perhaps  it  will  help  us  to 
understand  it,  if  we  bear  in  mind  that  in  a  large  proportion  of  cases 
convulsions  in  the  infant  answer  to  delirium  in  the  adult.  In  early  life 
the  superintendence  of  the  motor  power  is  the  chief  function  of  the  brain, 
which  has  not  yet  attained  to  its  highest  office  as  the  organ  of  the  in- 
tellect. Hence  the  convulsions  which  you  may  observe  to  come  on  in 
infancy  in  the  course  of  some  acute  diseases,  such  as  inflammation  of 
the  lungs,  do  not  import  that  any  new  malady  has  invaded  the  brain, 
but  simply  that  the  disease  is  so  serious  as  to  disturb  the  due  perform- 
ance of  all  the  functions  of  the  organism,  and  of  those  of  the  brain  in 
common  with  the  rest.  Convulsions  at  other  times  take  place  in  infancy 
not  as  the  result  of  any  abiding  disease  of  the  brain,  but  simply  in  con- 
sequence of  those  anatomical  peculiarities  which  allow  of  a  much  more 
sudden  and  more  considerable  congestion  of  the  cerebral  vessels  than 
can  occur  in  the  adult.  Of  this  kind  are  frequently  the  convulsions 
that  come  on  during  a  paroxysm  of  hooping-cough,  which  are  induced 
by  the  impediment  to  the  return  of  blood  from  the  head,  and  which 
often  cease  so  soon  as  that  impediment  is  removed  by  the  child  taking 
a  deep  inspiration.  But  these  two  considerations  are,  it  must  be  owned, 
by  no  means  adequate  to  explain  the  very  great  frequency  of  convul- 
sions in  children,  though  they  account  for  much  that  otherwise  would 
be  inexplicable. 

The  grand  reason  of  their  frequency  is  no  doubt  to  be  found  in  the 
predominance  of  the  spinal  over  the  cerebral  system  in  early  life.  In 
the  adult,  the  controlling  power  of  the  brain  checks  the  display  of  those 
reflex  movements  which  become  at  once  evident  if  disease  heighten  the 
excitability  of  the  spinal  cord,  or  cut  off  the  influence  of  the  brain  from 
the  paralysed  limb,  or  even  if  sleep  suspend  that  influence  for  a  season. 
When  the  child  is  born  the  brain  is  but  imperfectly  developed,  its  func- 
tions are  most  humble,  and  convulsions  are  then  so  frequent  that  they 
are  computed  to  occasion  73.3  per  cent,  of  all  deaths  which  take  place 
during  the  first  year  of  existence,  from  diseases  of  the  nervous  system. 
In  the  next  two  years  the  brain  more  than  doubles  its  weight,  and 
deaths  from  convulsions  sink  to  just  a  third  of  their  former  frequency. 
In  proportion  as  the  brain  increases  in  size,  and  its  structure  acquires 
perfection,  and  its  higher  functions  become  displayed,  convulsions  grow 
less  and  less  frequent,  until  from  the  10th  to  the  15th  year  they  cause 
less  than  3  per  cent.,  and  above  15  less  than  1  per  cent.,  of  the  deaths 
from  diseases  of  the  nervous  system.1 

1  The  first  line  in  this  table  shows  the  proportion  per  cent,  of  deaths  from  diseases  of 
the  nervous  system  at  different  ages,  to  the  deaths  from  all  causes  at  the  same  ages  in 


32 


CONVULSIONS — THEIR  EXCITING  CAUSES  VARIOUS. 


But  a  little  observation  will  show  you,  that  though  convulsions  are 
often  the  immediate  cause  of  death,  yet  this  fatal  event  is  rare  during 
childhood  in  comparison  with  those  instances  in  which  they  pass  off 
without  any  serious  result ;  and  that  in  proportion  to  their  frequency 
they  less  often  betoken  serious  disease  of  the  brain  in  the  child  than  in 
the  adult,  while  any  cause  which  greatly  excites  the  spinal  system  may 
be  attended  by  them.  The  disturbance  of  the  spinal  system,  which 
ushers  in  fever  in  the  adult,  shows  itself  by  shivering.  In  the  child,  the 
same  disturbance  often  shows  itself  not  by  shivering  but  by  convulsions ; 
or  convulsions  may  be  induced  by  a  constipated  state  of  the  bowels,  by 
the  presence  of  worms  in  the  intestinal  canal,  or  of  a  calculus  in  the 
kidney,  or  by  the  pressure  of  a  tooth  upon  the  swollen  gum.  Hence 
your  first  duty  is,  in  every  case,  to  ascertain  where  is  the  seat  of  the 
irritation  which  excited  the  nervous  system  to  this  tumultuous  reaction. 
If  the  fits  come  on  in  an  advanced  stage  of  some  serious  disease,  they 
are  probably  only  the  indications  that  death  is  busy  at  the  centres  of 
vitality ;  if  they  attack  a  child  labouring  under  hooping-cough,  they 
point  to  a  congested  state  of  the  brain,  the  consequence  of  the  impeded 
circulation  through  the  lungs ;  if  they  occur  in  a  child  apparently  in 
perfect  health,  they  probably  indicate  that  the  stomach  has  been  over- 
loaded, or  that  some  indigestible  article  of  food  has  been  taken  ;  or,  if 
that  be  certainly  not  the  case,  one  of  the  eruptive  fevers  is  perhaps  about 
to  come  on  ;  most  likely  either  small-pox  or  scarlatina. 

To  determine  the  cause  of  the  convulsions  you  must  acquaint  yourself 
with  the  history  of  the  child's  health  for  some  time  before  any  threaten- 
ing of  them  had  appeared ;  you  must  learn  whether  the  child  has  ever 
suffered  from  worms,  whether  its  digestive  functions  have  long  been  out 
of  order,  or  whether  the  process  of  dentition,  which  is  now  perhaps  going 
on,  has  been  attended  with  much  constitutional  disturbance.  But, 
besides  all  these  points,  your  inquiries  must  be  still  more  carefully 
directed  to  ascertain  whether  any  cerebral  symptoms  preceded  the 
attack,  and  if  so,  what  was  their  nature,  since  it  is  seldom  that  acute 
diseases  of  the  brain  sets  in  with  convulsions.  You  will  sometimes, 
indeed,  be  told  that  the  child  was  well  until  a  convulsive  seizure  sud- 
denly came  on  ;  but  on  inquiring  minutely  it  will  usually  be  found  that 
some  indications  of  cerebral  disease  had  been  present  for  days,  though 
not  sufficiently  severe  to  attract  much  attention.  In  cases  of  apoplexy, 
of  intense  cerebral  congestion,  and  of  phrenitis,  convulsions  occur  at  a 

the  metropolis ;  and  the  second  line  the  proportion  borne  by  deaths  from  convulsions  to 
deaths  from  diseases  of  the  nervous  system  in  general, 


Under  1 
year. 

From 
1  to  3 

years. 

From 
3  to  5 
years. 

Total 
under  5 
years. 

From 
5  to  10 
years. 

From 

10  to  15 

years. 

Total 

above  15 

years. 

30.5 
73.3 

18.5 
24.9 

17.6 
17.8 

24.3 
64.3 

15.1 
9.9 

10.6 
2.4 

10.4 
8 

Deduced  from  the  Fifth  and  Eighth  Reports  of  the  Registrar- General. 


PRECURSORS   OP  AN   ATTACK.  66 

very  early  period  ;  but  even  here,  extreme  drowsiness,  great  pain  in  the 
head,  and  vomiting,  usually  precede  for  a  few  hours  the  convulsive 
seizure.  When  the  brain  is  thus  seriously  involved,  the  recovery  from 
the  convulsions  is  very  imperfect,  coma  perhaps  succeeding  to  them,  or 
the  evidence  of  cerebral  disease  being  so  marked  as  to  leave  no  doubt  of 
the  brain  being  affected.  Tubercles  sometimes  remain  for  a  long  time 
after  its  deposition  in  the  brain,  without  giving  rise  to  any  well-marked 
symptoms,  its  presence  being  at  length  announced  by  a  fit  of  convul- 
sions. These  convulsions  are  seldom  at  first  very  severe,  but  you  will 
learn  to  dread  them  more  than  those  which  assume  a  more  formidable 
appearance,  from  noticing  either  that  one  side  of  the  body  is  exclusively 
affected,  or,  at  least,  that  there  is  a  marked  preponderance  of  the  affec- 
tion on  one  side.  It  is  well  to  bear  in  mind,  too,  that  convulsions  may 
occur  from  a  want  of  blood  in  the  brain  as  well  as  from  its  excess,  and 
that  the  convulsions  which  come  on  in  some  ill-nourished  infants  may 
indicate  a  state  of  atrophy  of  the  brain. 

I  must,  however,  have  said  enough  already  to  impress  upon  you  the 
importance  of  narrowly  scrutinising  the  meaning  of  every  attack  of  con- 
vulsions. But,  though  so  important,  there  are  few  tasks  more  difficult. 
You  have  to  maintain  your  own  self-composure  at  a  time  when  all 
around  you  have  lost  theirs ;  to  extract  truth  as  you  best  may  from 
the  imperfect,  often  exaggerated,  accounts  of  anxious  relatives;  to 
observe  not  only  minutely  but  quickly,  and  to  come  to  a  speedy  deci- 
sion :  since  while  in  those  cases  which  require  active  treatment  delay 
is  almost  synonymous  with  death,  there  is  at  least  as  great  danger  of 
destroying  your  patient  by  that  "nimia  diligentia"  to  which  the  pre- 
judices of  the  nurse  and  the  fears  of  the  friends  will  often  conspire  to 
urge  you. 

It  is  well  to  watch  closely  the  first  indications  of  that  disturbance  of 
the  nervous  system  which  will  be  likely  to  issue  in  convulsions.  And 
here  let  me  recommend  you  not  to  listen  with  too  incredulous  an  ear 
to  old  nurses,  who  may  tell  you  that  a  child  has  been  much  convulsed, 
while  you  find  upon  inquiry  that  it  has  not  had  any  fit.  When  they 
say  that  a  child  has  been  much  convulsed,  they  mean  usually  that  it 
has  shown  many  of  the  symptoms  which  forebode  an  attack  of  general 
convulsions.  These  forebodings  are  often  induced  by  dyspepsia,  or 
disorder  of  the  bowels  in  young  infants,  and  have  been  described  by 
writers  under  the  name  of  "inward  fits."  A  child  thus  affected  lies 
as  though  asleep,  winks  its  imperfectly  closed  eyes,  and  twitches  the 
muscles  of  the  face — a  movement  especially  observable  about  the  lips, 
which  are  drawn  as  though  into  a  smile.  Sometimes,  too,  this  movement 
of  the  mouth  is  seen  during  sleep,  and  poets  have  told  us  that  it  is  the 
"angel's  whisper"  which  makes  the  babe  to  smile, — a  pretty  conceit  of 
which  we  can  scarce  forgive  science  for  robbing  us.  If  this  condition 
increase,  the  child  breathes  with  difficulty,  its  respiration  sometimes 
seems  for  a  moment  almost  stopped,  and  a  livid  ring  surrounds  the 
mouth.  At  every  little  noise  the  child  wakes  up ;  it  makes  a  gentle 
moaning,  brings  up  the  *  milk  while  sleeping,  or  often  passes  a  great 
quantity  of  wind,  especially  if  the  abdomen  be  gently  rubbed.  When 
the  intestinal  disorder  is  relieved,  these  symptoms  speedily  pass  away 

3 


34  DESCRIPTION   OF  A  FIT.' 

nor  have  we  much  reason  to  fear  general  convulsions  so  long  as  no 
more  serious  forebodings  show  themselves.  There  is  more  cause  for 
apprehension,  however,  when  we  see  the  thumbs  drawn  into  the  palm 
either  habitually  or  during  sleep ;  when  the  eyes  are  never  more  than 
half  closed  during  sleep ;  when  the  twitching  of  the  muscles  is  no  longer 
confined  to  the  angles  of  the  mouth,  but  affects  the  face  and  extremi- 
ties ;  when  the  child  awakes  with  a  sudden  start,  its  face  growing 
flushed  or  livid,  its  eyes  turning  up  under  the  upper  eyelid,  or  the 
pupils  suddenly  dilating,  while  the  countenance  wears  an  expression  of 
great  anxiety  or  alarm,  and  the  child  either  utters  a  shriek  or  some- 
times begins  to  cry. 

When  a  fit  comes  on,  the  muscles  of  the  face  twitch,  the  body  is  stiff, 
immoveable,  and  then  in  a  short  time,  in  a  state  of  twitching  motion, 
the  head  and  neck  are  drawn  backwards,  and  the  limbs  violently  flexed 
and  extended.  Sometimes  these  movements  are  confined  to  certain 
muscles,  or  are  limited  to  one  side.  At  the  same  time  neither  con- 
sciousness nor  sensation  is  present.  The  eye  is  fixed  and  does  not  see ; 
the  finger  may  be  passed  over  it  without  winking;  the  pupil  is  immove- 
ably  contracted  or  dilated ;  the  ear  is  insensible  even  to  loud  sounds ; 
the  pulse  is  small,  very  frequent,  often  too  small  and  too  frequent  to 
be  counted ;  the  breathing  hurried,  laboured,  and  irregular ;  the  skin 
bathed  in  abundant  perspiration. 

After  this  condition  has  lasted  for  a  minute,  or  ten  minutes,  or  an 
hour  or  more,  the  convulsions  cease ;  and  the  child  either  falls  asleep, 
or  lies  for  a  short  time  as  if  it  were  bewildered,  or  bursts  into  crying, 
and  then  returns  to  its  senses,  or  sinks  into  a  state  of  coma  in  which  it 
may  either  be  perfectly  motionless,  or  twitching  of  some  muscles  may 
still  continue ;  or,  lastly,  it  may  die  in  the  fit.  This,  however,  is  not 
usual  except  when  the  convulsions  have  come  on  in  subjects  exhausted 
by  previous  disease,  or  when  they  are  the  result  of  apoplexy  or  intense 
cerebral  congestion,  such  as  takes  place  occasionally  in  hooping-cough, 
or  when  they  are  associated  with  that  closed  state  of  the  larynx  which 
occurs  sometimes  in  spasmodic  croup. 

This  preliminary  examination  of  the  symptoms  of  disturbance  of  the 
nervous  system  has  placed  us  in  a  position  to  commence  our  investiga- 
tion of  the  different  forms  of  cerebral  disease,  on  which  we  will  enter 
at  the  next  lecture. 


LECTURE    III. 

Congestion  of  the  Brain. — Active  congestion  may  come  on  at  the  onset  of  eruptive 
fevers,  or  be  induced  by  exposure  to  the  sun,  or  may  attend  dentition  or  be  excited 
by  various  other  causes — Symptoms  in  each  of  its  three  stages — Treatment — Special 
rules  for  depletion  and  the  application  of  cold — Active  measures  not  always  appro- 
priate— Passive  congestion  may  supervene  on  hooping-cough,  or  be  connected  with 
disorder  of  the  digestive  organs  in  weakly  children,  or  be  induced  by  unfavourable 
hygienic  causes — Its  symptoms  and  treatment. 

In  my  last  lecture  I  endeavoured  to  point  out  to  you  some  of  the 
reasons  for  the  greater  frequency  of  affections  of  the  nervous  system 


ACTIVE  CONGESTION    OE  THE  BRAIN.  35 

in  infancy  and  childhood  than  at  other  periods  of  life.  I  dwelt  espe- 
cially upon  certain  structural  peculiarities  of  the  brain,  and  of  its  bony 
case,  which  render  the  cerebral  vessels  liable  to  become  overloaded  with 
blood,  under  the  influence  of  causes  that  would  be  wholly  inadequate  to 
produce  such  an  eiFect  in  the  adult.  With  the  advance  of  the  ossifica- 
tion of  the  skull,  and  the  closure  of  its  fontanelles  and  sutures,  these 
peculiarities  are  rendered  fewer  and  less  important;  but  still  a  remark- 
able liability  to  congestion  of  its  vessels  continues  to  characterize  the 
brain  through  all  the  years  of  early  childhood.  A  distinguished 
German  physician,  Dr.  Mauthner,  of  Vienna,1  on  examining  the  bodies 
of  229  children  who  had  died  at  different  ages  and  of  various  diseases, 
found  a  congested  state  of  the  vessels  of  the  brain  in  186  of  the  number. 
In  some  of  these  cases  it  is  probable  that  this  condition  had  come  on 
only  a  short  time  before  the  patients'  death,  since  in  them  no  symp- 
toms of  cerebral  disturbance  had  appeared  during  the  progress  of  their 
illness ;  but  in  many  it  was  not  so  ;  and  I  shall  have  occasion  to  warn 
you  over  and  over  again  to  be  on  the  watch  against  congestion  of  the 
brain,  as  a  condition  which  is  very  likely  to  come  on  in  the  course  of 
affections  even  of  distant  organs.  Nor  is  it  merely  as  a  serious  com- 
plication of  many  other  diseases  that  this  cerebral  congestion  deserves 
your  notice;  its  importance  depends  still  more  on  its  constituting  the 
first  and  curable  stage  of  many  diseases  of  the  brain,  which,  unless 
arrested  at  the  outset,  soon  pass  beyond  the  resources  of  our  art.  Neither, 
indeed,  must  it  be  forgotten,  that  although  inflammation,  haemorrhage, 
and  the  effusion  of  serum,  are  the  three  results  to  one  or  other  of  which 
congestion  of  the  cerebral  vessels  tends,  yet  the  exceptions  to  their 
occurrence  are  by  no  means  few,  even  when  that  congestion  has  been 
very  considerable  or  of  long  continuance ;  and  that  not  only  may  the 
functions  of  the  brain  be  seriously  disordered,  but  the  life  of  the  patient 
may  be  destroyed,  without  the  anatomist  being  able  to  discover  any  one 
of  these  results,  or,  indeed,  any  thing  more  than  a  general  repletion  of 
the  vessels  of  the  organ.3 

Any  cause  which  greatly  increases  the  flow  of  blood  to  the  head,  or 
which  greatly  impedes  its  reflux,  may  give  rise  to  a  congested  state  of 
the  brain ;  and,  according  as  this  state  is  induced  by  the  one  or  the 
other  cause,  it  is  said  to  be  active  or  passive.  The  head  symptoms  which 
sometimes  usher  in  the  eruptive  fevers  depend,  in  a  measure,  upon  the 
former  cause  ;  the  convulsions  which  frequently  occur  during  a  fit  of 
hooping-cough  result  from  the  latter.  The  brain  may  become  actively 
congested  at  the  time  of  teething,  or  from  exposure  to  the  sun,  or  from 
a  blow  on  the  head ;  or  a  state  of  passive  congestion  may  be  induced  by 
some  mechanical  impediment  to  the  return  of  blood  from  the  organ — 
such  as  the  pressure  of  a  hypertrophied  thymus,  or  of  enlarged  and 
tuberculated  bronchial  glands  upon  the  jugular  veins,  or  it  may  be  merely 
the  result  of  a  languid  circulation  from  the  want  of  pure  air,  or  of 
nourishing  and  sufficient  food. 

1  Die  Krankheiten  des  Gehirns  und  Riickenmarks  bei  Kindern.  8vo.  Wien,  1844,  p.  12. 

2  Dietl's  Anatomische  Klinik  der  Gehirnkrankheiten,  8vo.  Wien,  1846,  contains,  at 
pp.  53 — 735  a  very  able  exposition  and  defence  of  views  concerning  cerebral  congestion 
in  many  respects  similar  to  those  expressed  in  this  lecture. 


36  ACTIVE   CONGESTION   OF   THE   BRAIN. 

Active  cerebral  congestion  is  not  a  very  unusual  consequence  of  the 
disturbance  of  the  circulation  at  the  outset  of  the  eruptive  fevers.  Con- 
vulsions and  apoplectic  symptoms  sometimes  come  on  suddenly  in  a 
child  previously,  to  all  appearance,  in  perfect  health,  and  may  even 
terminate  in  death  in  less  than  twenty-four  hours.  The  brain  is  found 
loaded  with  blood,  but  all  the  other  organs  of  the  body  are  quite  healthy. 
A  year  or  two  ago  I  was  requested  to  be  present  at  the  examination  of 
the  body  of  a  boy  not  quite  two  years  old,  who  had  been  in  perfect 
health  until  the  day  before  his  death,  which  took  place  under  such  circum- 
stances as  I  have  just  mentioned.  The  congested  state  of  the  cerebral 
vessels  gave  but  little  satisfactory  information ;  but  the  same  evening, 
the  brother  of  the  child  was  taken  ill  with  vomiting,  intense  fever,  and 
sore-throat.  In  a  few  hours  a  red  rash  appeared  ;  the  case  was  one  of 
scarlet  fever,  and  ran  its  course  with  considerable  severity,  though, 
happily,  to  a  favourable  termination.  It  is  probable  that  the  poison  of 
the  fever  had  affected  the  blood  of  both  children,  and  that  the  conse- 
quent disturbance  of  the  cerebral  circulation  was  so  violent  as  at  once 
to  destroy  the  life  of  the  younger,  while  the  elder  brother  survived  the 
shock,  and  in  him  the  disease  soon  presented  its  usual  features.  The 
history  of  most  epidemics  of  scarlatina  would  afford  you  many  instances 
of  a  similar  nature."1 

But,  alarming  though  these  symptoms  are,  it  is  comparatively  seldom 
they  end  in  death ;  for  when  they  occur  at  the  onset  of  the  exanthe- 
mata they  generally  disappear  almost  as  if  by  magic  on  the  appearance 
of  the  eruption. 

I  was  called  one  day  to  see  a  little  girl  two  years  old,  who,  until  the 
day  before,  had  never  had  an  hour's  illness.  She  had  eaten  a  hearty 
dinner ;  and,  though  she  vomited  soon  afterwards,  did  not  seem  otherwise 
indisposed,  and  slept  well  in  the  night.  Immediately  on  waking  in  the 
morning,  however,  she  had  a  fit,  during  which  she  was  insensible,  squinted, 
threw  her  limbs  about,  and  occasionally  screamed  aloud.  She  continued 
very^ill  through  the  whole  day;  was  hot  and  feverish  during  the  night, 
having  occasional  attacks  of  convulsions,  in  which  she  stretched  out  her 
legs,  threw  back  her  head,  now  and  then  uttered  a  word  or  two,  and  then 
relapsed  into  a  state  of  insensibility.  This  was  her  state  at  half-past 
10  A.  M. — about  twenty-four  hours  after  the  occurrence  of  the  first  fit. 
I  bled  her,  put  eight  leeches  on  her  head,  employed  cold  affusion,  and 
gave  active  cathartics  during  the  day,  but  without  much  benefit ;  and  at 
midnight  she  was  still  insensible,  rolling  uneasily  from  side  to  side, 
boring  with  her  head  in  the  pillow,  squinting,  and  making  automatic 
movements  with  her  mouth  and  tongue.  I  now  put  eight  more  leeches 
on  the  head,  which  bled  profusely,  and  the  bleeding  was  followed  by 
great  diminution  in  the  convulsive  movements.  About  4  A.  M.  of  the 
next  day,  the  child  fell  asleep,  and  dozed  for  a  few  hours.  She  awoke 
sensible,  and  continued  so.  On  my  visit  in  the  morning,  I  found  her 
quiet  and  sensible,  without  any  sign  of  convulsion ;  her  face  was  very 

'See  Armstrong's  notice  of  this  suddenly  fatal  form  of  the  disease,  at  p.  30  of  his' 
work  on  Scarlet  Fever,  &c.  2d  edit.  London,  1817 ;  and  Von  Amnion's  mention  of  it  in 
his  description  of  the  epidemic  of  malignant  scarlatina  at  Dresden  in  1831-2,  in  the 
Analekten  ubcr  Kinderkrankheiten,  lltes  Heft,  p.  42.     Stuttgart,  183(3. 


CAUSES   PRODUCING   IT.  37 

pale ;  her  head,  before  so  hot,  was  now  quite  cool;  her  pulse  had  sunk 
in  frequency,  and  lost  its  fulness.  An  eruption  of  a  popular  character 
had  appeared  on  the  hands,  arms,  inside  of  the  thighs,  and  slightly  on 
the  face.  This  eruption  was  the  small-pox,  and  the  disease  ran  its  course 
with  no  unfavourable  symptom. 

It  would  not  be  right,  indeed,  to  attribute  the  symptoms  of  disturbance 
of  the  nervous  system  that  sometimes  occur  at  the  commencement  of  the 
eruptive  fevers  entirely  to  derangement  of  the  cerebral  circulation,  for 
something  is  probably  due  to  changes  in  the  blood  itself;  but  we  see 
similar  results  produced  by  other  causes,  the  immediate  effect  of  which 
is  to  disturb  the  circulation  and  to  favour  congestion  of  the  brain. 
Thus,  exposure  to  the  heat  of  the  sun,  even  though  the  head  had  not 
been  unprotected  from  its  rays,  may  be  followed  by  convulsions  or 
other  indications  of  an  overloaded  state  of  the  brain,  and  these  symp- 
toms may  all  subside  so  soon  as  the  excited  circulation  has  recovered 
its  wonted  balance.  Of  this  I  recently  saw  a  striking  instance  in  the 
case  of  a  delicate  boy,  who,  when  a  year  old,  was  taken  out  by  his 
nurse  during  one  of  the  hottest  days  in  June.  He  was  quite  well  and 
cheerful  when  he  left  the  house,  but,  after  being  out  for  some  time, 
began  to  breathe  hurriedly  and  irregularly,  and  his  nurse,  in  conse- 
quence, brought  him  home.  I  saw  him  about  two  hours  afterwards. 
He  was  then  restless,  fretful,  and  alarmed ;  his  surface  generally  hot, 
and  his  head  especially  so,  the.  brain  pulsating  forcibly  through  the 
anterior  fontanelle  ;  the  pulse  too  rapid  to  be  counted  ;  the  respiration 
hurried,  laboured,  and  irregular,  and  there  were  constant  startings  of 
the  tendons  of  the  extremities.  The  child  was  on  the  eve  of  an  attack 
of  convulsions,  but  the  tepid  bath  relieved  the  heat  of  the  skin,  and  the 
pulse  fell,  and  the  subsultus  diminished.  Light  and  sound  were 
excluded  from  the  room ;  he  fell  asleep,  and  awoke  in  a  few  hours 
refreshed  and  tranquillized,  and  on  tbe  next  morning  a  little  languor 
was  all  that  remained  of  an  illness  which  had  seemed  likely  to  prove  so 
formidable. 

Disorders  of  the  nervous  system  are  very  frequent  during  the  period 
of  teething,  Many  of  the  symptoms  which  then  occur  are  the  direct 
result  of  irritation  of  the  trifacial  nerve,  but  others  are  the  immediate 
consequence  of  congestion  of  the  brain.  Febrile  disturbance  almost 
always  attends  upon  the  process  of  dentition,  and  you  can  easily  under- 
stand that  when  the  circulation  is  in  a  state  of  permanent  excitement, 
a  very  slight  cause  may  suffice  to  overturn  its  equilibrium,  and  occasion 
a  greater  flow  of  blood  to  the  brain  than  the  organ  is  able  to  bear. 

But  I  need  not  occupy  more  time  in  pointing  out  to  you  the  various 
circumstances  which  may  give  rise  to  active  congestion  of  the  brain. 
Let  us  now  pass  to  a  more  minute  examination  of  its  symptoms. 

Cerebral  congestion  may,  as  you  have  seen,  come  on  very  suddenly, 
its  symptoms  from  the  first  being  alarming,  and  such  as  to  call  for 
immediate  interference  ;  or  general  uneasiness,  a  disordered  state  of 
the  bowels,  which  are  generally,  though  not  invariably  constipated,  and 
feverishness,  may  have  for  a  few  days  preceded  the  more  serious  attack. 
The  head  by  degrees  becomes  hot,  the  child  grows  restless  and  fretful, 
and  seems  distressed  by  light,  or  noise,  or  sudden  motion,  and  children 


38     "  CEREBRAL   CONGESTION — ITS   SYMPTOMS. 

who  are  old  enough  sometimes  complain  of  their  head;  One  little  boy, 
nearly  three  years  old,  who  died  of  congestion  of  the  brain,  had  seemed 
to  suffer  for  some  days  before  any  alarming  symptom  came  on,  from 
severe  pain  in  the  head.  He  sometimes  awoke  crying  from  his  sleep, 
or  when  awake  would  suddenly  put  his  hands  to  his  ears,  exclaiming, 
"  Oh,  hurt !  hurt !"  Usually,  too,  vomiting  occurs  repeatedly,  a 
symptom  on  the  importance  of  which  I  have  already  insisted,  since  it 
is  not  only  confirmatory  of  others,  but  also  may  exist  before  there  is 
any  well-marked  indication  of  the  head  being  affected,  and  when, 
though  the  child  seems  ailing,  there  is  nothing  definite  about  its  illness. 
The  degree  of  fever  which  attends  this  condition  varies  much,  and  its 
accessions  are  irregular ;  but  the  pulse  is  usually  much  and  permanently 
quickened ;  and  if  the  skull  be  unossified,  the  anterior  fontanelle  is 
either  tense  and  prominent,  or  the  brain  is  felt  and  seen  to  pulsate 
forcibly  through  it.  The  sleep  is  disturbed,  the  child  often  waking 
with  a  start,  while  there  is  occasional  twitching  of  the  muscles  of  its 
face,  or  the  tendons  of  its  wrist. 

The  child  may  continue  in  this  condition  for  many  days,  and  then 
recover  its  health  without  any  medical  interference  ;  but  a  slight  cause 
will  generally  suffice  to  bring  back  the  former  indisposition.  You  will 
sometimes  see  striking  instances  of  this  in  children  while  teething ; 
the  fever  subsiding,  the  head  growing  cool,  and  the  little  patient 
appearing  quite  well,  so  soon  as  the  tooth  has  cut  through  the  gum, 
but  the  approach  of  each  tooth  to  the  surface  being  attended  by  the 
recurrence  of  the  same  symptoms. 

But  though  the  disturbance  of  the  brain  may  pass  away  of  its  own 
accord,  yet  we  cannot  reckon  on  such  a  favourable  result  occurring, 
for  symptoms  such  as  I  have  mentioned  are  often  the  indications  of  the 
organism  generally  having  begun  to  suffer  from  mischief  which  has 
been  going  on  for  months  unnoticed,  and  which  is  now  about  to  break 
out  with  all  the  formidable  characters  of  acute  hydrocephalus.  Or 
should  they  have  no  such  serious  import,  yet  congestion  of  the  brain  is 
itself  a  serious,  sometimes  a  fatal  malady.  Even  though  no  treatment 
be  adopted,  indeed,  the  heat  of  head  may  diminish,  and  the  flush  of 
the  face  grow  slighter  and  less  constant,  but  the  countenance  becomes 
very  heavy  and  anxious,  the  indifference  to  surrounding  objects 
increases,  and  the  child  lies  in  a  state  of  torpor  or  drowsiness ;  from 
which,  however,  it  can  at  first  be  roused  to  complete  consciousness. 
The  manner,  on  being  roused,  is  always  fretful ;  but  if  old  enough  to 
talk,  the  child's  answers  are  rational,  though  generally  very  short  ; 
and,  murmuring  "I  am  so  sleepy,  so  .sleepy,"  it  subsides  into  its 
former  drowsiness.  The  bowels  generally  continue  constipated,  and 
the  vomiting  seldom  ceases,  though  it  is  sometimes  less  frequent  than 
before.  The  pulse  is  usually  smaller  than  in  the  other  stage,  and 
there  is  often  irregularity  in  its  frequency,  though  no  actual  intermis- 
sion. An  attack  of  convulsions  sometimes  marks  the  transition  from 
the  first  to  the  second  stage ;  or  the  child  passes,  without  any  apparent 
cause,  from  its  previous  torpor  into  a  state  of  convulsion,  which  sub- 
siding, leaves  the  torpor  deeper  than  before.  The  fits  return,  and 
death  may  take  place  in  one  of  them,  or  the  torpor  growing  more 


ITS   TREATMENT.  39 

profound  after  each  convulsive  seizure,  the  child  at  length  dies 
comatose. 

This  second  stage,  if  so  it  may  he  called,  is  usually  of  short  duration, 
and  if  relief  be  not  afforded  by  appropriate  treatment,  death  is  seldom 
delayed  beyond  forty-eight  hours  from  the  first  fit,  though  no  graver 
lesion  may  be  discovered  afterwards  than  a  gorged  state  of  the  vessels 
of  the  brain  and  its  membranes,  and  perhaps  a  little  clear  fluid  in  the 
ventricles  and  beneath  the  arachnoid. 

Occasionally,  indeed,  death  does  not  so  speedily  follow  these  symp- 
toms ;  but  they  continue  slightly  modified  for  days,  or  even  weeks,  and, 
contrary  to  all  expectation,  recovery  now  and  then  takes  place.  This 
protracted  course  of  the  affection  is,  I  believe,  met  with  only  in  the 
case  of  very  young  children,  in  whom,  the  congestion  having  relieved 
itself  by  a  copious  effusion  of  serum  into  the  ventricles,  the  yielding 
skull  accommodates  itself  to  its  increased  contents.  The  symptoms, 
though  to  a  great  extent  the  same  as  before,  are  now  due  to  the 
presence  of  water  in  the  brain — a  disease  which,  though  dangerous 
and  often  fatal,  is  yet  chronic  in  its  course,  and  may  even  admit  of 
cure. 

If  active  congestion  of  the  brain  may  come  on  under  so  great  a 
variety  of  circumstances,  it  is  evident  that  there  can  be  no  invariable 
rule  for  its  treatment,  adapted  alike  to  every  case,  but  that  the  pecu- 
liarities of  each  must  be  taken  into  your  most  careful  consideration. 
The  little  girl  I  have  mentioned  in  whom  convulsions  preceded  the 
attack  of  small-pox,  would  most  likely  have  died  from  apoplexy  if  she 
had  not  been  bled ;  and  it  is  probable  that  in  her  case  the  depletion 
might  have  been  carried  still  further  with  advantage.  On  the  other 
hand,  the  boy  who  had  been  exposed  to  the  heat  recovered  under  the 
tranquillizing  influence  of  a  tepid  bath,  and  there  can  be  no  doubt  but 
that  to  him  depletion  would  have  been  injurious.  You  must,  then, 
always  endeavour  to  make  out  what  has  been  the  antecedent  of  the 
attack.  If  violent  convulsions  have  come  on  suddenly,  and  without 
apparent  cause,  in  a  child  until  a  short  time  before  in  perfect  health, 
inquire  whether  your  patient  has  had  the  eruptive  fevers,  especially 
scarlatina  and  small-pox,  or  whether  he  has  been  recently  exposed  to 
their  contagion,  and  examine  the  arm  to  see  whether  there  is  a  good 
cicatrix  as  evidence  of  successful  vaccination.  When  head  symptoms 
usher  in  the  exanthemata,  the  danger  for  a  time  may  be  imminent,  but 
you  know  that  if  you  can  relieve  the  gorged  vessels  of  the  brain,  and 
thus  ward  off  the  immediate  peril,  nature  herself  will  come  to  your 
assistance,  and  the  outbreak  of  the  eruption  will  probably  be  followed 
by  the  cessation  of  the  cerebral  disturbance.  Or  it  may  be  that  the 
child  has  greatly  overloaded  its  stomach,  or  partaken  of  some  indiges- 
tible substance,  in  which  case  you  would  give  an  emetic,  though  under 
any  other  circumstances  the  attempt  to  induce  vomiting  would  be  not 
only  useless  but  dangerous.  If  the  symptoms  had  succeeded  to  a  blow, 
you  would  not  lose  sight  of  the  danger  of  inflammation  of  the  brain 
supervening :  while  if  the  head  affection  had  been  preceded  by  long- 
continued  gastric  or  intestinal  disturbance,  or  if  it  had  come  on  during 
teething,  you  would  bear  in  mind  that  a  more  cautious  treatment  must 


40  RULES   FOR   DEPLETION. 

be  pursued,  lest  you  cause  as  serious  mischief  by  doing  too  much,  as 
might  in  other  cases  result  from  your  doing  too  little. 

There  are,  however,  but  few  exceptions  to  the  rule  which  prescribes 
the  abstraction  of  blood,  either  locally  or  generally,  as  one  of  the  most 
important  remedies  in  cases  of  active  cerebral  congestion.  If  the 
symptoms  set.  in  violently,  as  they  did  in  the  case  of  the  little  girl 
whose  history  I  mentioned  to  you,  you  must  deplete  freely,  and  will 
find  that  relief  will  follow  more  speedily  on  the  abstraction  of  blood 
from  the  jugular  vein  than  on  venesection  or  the  application  of  leeches. 
It  is  not  easy  to  define  exactly  the  quantity  of  blood  which  may  be 
drawn,  but  from  two  to  three  ounces  would  probably  be  as  much  as  you 
would  ever  be  warranted  in  taking  from  a  child  a  year  old ;  and  the 
appearance  of  manifest  relief  to  the  symptoms  should  be  a  signal  to 
you  for  stopping  its  flow,  even  before  that  quantity  had  been  obtained. 
The  removal  of  too  large  a  quantity  of  blood  would  be  at  least  as  mis- 
chievous as  the  abstraction  of  too  little,  while  you  would  run  some 
hazard  of  confounding  the  effects  of  loss  of  blood  with  those  of  its 
excess,  and  might  thus  be  led  further  into  error.  It  is,  therefore, 
better  (although  children  bear  repeated  blood-letting  ill)  to  take  but  a 
moderate  quantity  of  blood  at  first ;  to  watch  its  effects,  and  to  repeat 
the  bleeding  in  a  few  hours,  if  it  be  necessary,  rather  than  to  subject 
the  system  to  the  shock  of  an  excessive  loss  of  blood. 

In  children  under  eighteen  months  old,  bleeding  from  the  arm  is 
seldom  practicable,  and,  without  the  case  be  very  urgent,  it  is  inex- 
pedient to  open  the  jugular  vein.  At  this  early  age,  however,  almost 
all  the  good  effects  of  general  bleeding  can  be  obtained  by  the  applica- 
tion of  leeches.  You  will,  probably,  not  be  far  wrong  if  you  estimate 
the  quantity  of  blood  drawn  by  a  healthy  leech  at  about  3ij.,  and,  if 
the  subsequent  bleeding  be  encouraged,  about  as  much  will  flow  after- 
wards. In  cases  such  as  these,  however,  where  too  little  and  too  much 
are  alike  attended  by  most  serious  danger,  you  must  not  content 
your  selves  with  ordering  a  certain  number  of  leeches,  and  leaving  their 
application  to  a  nurse,  and  the  regulation  of  the  subsequent  bleeding  to 
accident,  but  must  attend  and  watch  the  effects  they  produce. 

If,  on  your  second  visit,  you  find  that  the  child,  although  manifestly 
relieved  for  a  time  by  the  depletion,  is  relapsing  into  a  state  of  coma, 
or  that  convulsions,  checked  for  a  season,  are  returning,  or  that  the 
head  is  nearly  as  hot,  and  the  pulse  nearly  as  accelerated  as  before, 
and  quite  as  hard,  you  may  be  warranted  in  bleeding  again.  Such 
depletion  should  be  local,  and,  if  you  can  obtain  the  assistance  of  an 
expert  cupper,  it  will  be  better,  in  the  case  of  children  above  three  or 
four  years  old,  to  draw  blood  by  cupping  from  the  back  of  the  neck 
rather  than  by  leeches.  You  must  not  however,  resort  to  a  second 
bleeding  without  the  most  evident  necessity,  nor  without  having  tried 
all  those  subsidiary  means  by  the  diligent  employment  of  which  you  will 
often  be  able  to  render  further  depletion  unnecessary.  Many  of  these 
means,  indeed,  are  so  simple  that  their  value  is  frequently  underrated; 
and  it  is  so  often  said,  almost  as  a  matter  of  course,  "keep  the  child 
quiet  and  the  room  cool,  and  apply  cold  to  the  head,"  that  it  does  not 
strike  the  parents  how  much  depends  upon  those  directions  on  which 


APPLICATION   OF   COLD.  41 

the  doctor  seems  to  lay  so  little  weight.  You  must  learn,  however,  that 
in  the  treatment  of  children's  diseases  none  of  these  things  are  trivial, 
but  that  on  their  due  performance  often  hangs  the  life  of  your  patient. 
Do  not  content  yourselves,  then,  with  merely  giving  directions,  but 
stay  to  see  them  attended  to ;  and  do  not  leave  the  house  till  the 
chamber  has  been  darkened  ;  the  cool  air  is  freely  admitted,  the  cold 
application  to  the  head  has  been  properly  adjusted,  and  all  persons  who 
are  not  actually  waiting  on  the  child  have  left  the  apartment. 

At  the  outset  of  the  affection  the  bowels  are  usually  constipated,  so 
that  an  active  purgative  is  in  most  cases  called  for.  You  may  give  a 
dose  of  calomel  and  jalap,  or  the  calomel  may  be  administered  alone 
and  followed  by  the  infusion  of  senna,  which  may  be  repeated  every 
three  or  four  hours  till  the  bowels  act.  Should  the  stomach  be  very 
irritable,  a  larger  dose  of  calomel  may  be  given,  and  after  the  lapse  of 
a  couple  of  hours  an  attempt  may  be  made  to  quicken*its  action  by 
administering  a  purgative  enema,  or  by  dissolving  some  sulphate  of 
magnesia  in  the  child's  drink,  and  giving  it  at  short  intervals.  In 
many  cases  the  disorder  will  be  speedily  removed  by  this  treatment, 
and  the  child,  whose  life  had  seemed  to  be  hanging. by  a  thread, will, 
in  the  course  of  twenty-four  hours,  be  almost  well. 

But  it  may  happen  that  though  the  symptoms  are  increasing  in 
severity,  though  the  convulsions  are  unchecked,  or  coma  is  evidently 
coming  on,  yet  the  state  of  the  pulse  forbids  a  repetition  of  depletion ; 
or  it  may  even  be  that  you  dare  not  bleed  at  all,  for  fear  of  altogether 
putting  out  the  life  which  is  in  such  urgent  peril.  Fortunately  we  have 
another  and  very  powerful  remedy  in  store,  which  we  may  try  in  cases 
where,  otherwise  we  should  be  without  resource  :  this  remedy  is  the 
cold  affusion.  There  is  something,  however,  apparently  so  formidable 
in  taking  a  child  from  its  bed  and  pouring  a  stream  of  cold  water  on 
its  head  for  several  minutes  together,  that  you  will  be  wise  to  explain 
what  you  are  about  to  do  to  the  child's  friends,  and  to  obtain  their 
consent  to  the  experiment,  lest  you  be  compelled  by  their  alarm  to 
desist  before  you  have  done  any  real  good.  When  you  have  de- 
termined to  resort  to  it,  the  child  must  be  taken  out  of  bed,  wrapped 
in  a  blanket,  and  laid  upon  the  nurse's  lap  with  its  face  downwards, 
while  you  pour  a  stream  of  water,  from  a  little  height,  upon  its  head. 
The  most  effectual  way  of  doing  this,  though  one  not  always  practicable, 
is  to  place  the  child  under  the  cock  of  a  water  cistern,  or  the  spout  of 
a  pump,  since  you  can  then  continue  the  stream,  uninterruptedly,  for 
five  or  six  minutes.  I  have  seen  some  remarkable  instances  of  con- 
vulsions arrested  and  of  children  aroused  from  coma,  by  these  means  ; 
but  you  must  bear  in  mind  that  the  agent  is  one  of  great  power, 
and  you  must  feel  the  pulse  from  time  to  time,  during  its  employment, 
lest  you  should,  by  its  long  continuance,  produce  too  great  a  depression 
of  the  vital  energies. 

But  besides  those  cases  in  which  you  want  to  produce  a  sudden 
effect  by  the  application  of  cold  with  a  shock,  you  often  need  the 
sedative  influence  of  cold  constantly  applied.  A  very  intense  degree 
of  cold  may  be  kept  up  by  allowing  cold  water  to  drip  constantly  upon 
the   patient's   head,  which  may  be   managed,  as   suggested   by  Dr. 


42  APPLICATION  OF  COLD. 

"Watson,  by  means  of  a  sponge  and  funnel  placed  a  little  above  the 
head.  This  plan  is,  however,  objectionable  on  account  of  its  being 
almost  impossible,  when  it  is  adopted,  to  prevent  the  patient's  person 
from  becoming  extremely  wet ;  and,  moreover,  it  is  but  seldom  that  so 
powerful  an  agent  is  needed  in  the  case  of  children.  Few  methods  of 
applying  cold  to  the  head  are  better  than  that  which  consists  in  half 
filling  two  bladders  with  pounded  ice  or  cold  water,  and  placing  them, 
each  wrapped  in  a  napkin,  the  one  under,  and  the  other  upon  the 
child's  head.  By  pinning  the  corners  of  the  napkins  to  the  pillow  you 
can  secure  them  from  being  displaced,  and  can  also  prevent  the  weight 
of  the  upper  bladder  from  resting  too  heavily  on  the  child's  head,  while 
all  danger  of  the  bed  or  the  dress  becoming  wet  is  avoided. 

Supposing,  now,  that  by  the  employment  of  these  means  you  have 
removed  the  imminent  danger,  and  that  your  patient  is  going  on  favour- 
ably, still  it  Will  be  generally  desirable  to  continue  treatment  for  a  few 
days.  Free  action  of  the  bowels  must  be  secured  ;  for  which  purpose 
small  doses  of  calomel  may  be  given  two  or  three  times  a  day,  and  it 
may  be  desirable  to  accompany  each  powder  with  a  dose  of  a  mixture 
containing  nitre  and  sulphate  of  magnesia.1     You  must,  however,  bear 

(No.  l.) 

1  R  Potassse  Nitratis,  gr.  x. 
Magnesias  Sulph.  gj. 
Syr.  Limonum,  sjiij. 

Aquas  destill.  gix.     M.     sjij.  ter  quotidie. 
For  a  child  a  year  old. 

in  mind  that  you  will  do  less  harm  by  allowing  a  child  to  go  without 
medicine  than  by  forcing  on  it  remedies  which  it  dislikes  and  resists 
taking.  Calomel,  indeed,  can  almost  always  be  given  ;  and  even  sul- 
phate of  magnesia  will  very  often  be  taken  if  mixed  with  the  drink, 
or  dissolved  in  a  little  veal  broth.  But  how  much  soever  a  child  may 
resist  medicine,  the  abstraction  of  blood,  a  spare  diet,  a  cool  and  dark 
and  quiet  chamber,  are  remedies  always  at  command,  the  value  of 
which  you  must  not  underrate. 

I  need  not  tell  you  that  all  cases  do  not  admit  of  this  active  treat- 
ment. When  the  disease  creeps  on  with  febrile  symptoms,  occasional 
vomiting,  constipation,  loss  of  appetite,  and  restless  nights,  with  com- 
plaints, if  the  child  be  old  enough  to  speak,  of  pain  in  the  head  or 
limbs,  or  vertigo,  and  with  a  quick  and  variable  pulse,  you  must  treat 
it  gently.  If  you  deplete,  it  must  be  only  by  leeches,  and  then  not  in 
large  number,  while  you  trust  much  to  quiet  and  the  careful  regulation 
of  the  diet.  In  such  cases  you  will  often  find  a  tepid  bath  night  and 
morning  soothe  the  child  and  tranquillize  the  circulation  far  more  than 
you  might  have  expected  from  so  simple  a  remedy.  Drastic  purgatives 
must  be  avoided,  but  small  doses  of  mercury  and  chalk,  or  of  calomel, 
either  alone  or  combined  with  rhubarb,  may  be  given  with  advantage 
once  or  twice  a  day.  Half  a  grain  of  calomel,  or  two  grains  of  the 
Hydr.  c.  Cret&,  with  four  of  rhubarb,  would  be  a  proper  dose  for  a 
child  a  year  old.     If  there  be  much  feverishness   and   restlessness 


ACTIVE   SYMPTOMS   SOMETIMES  IMPROPER.  43 

during  the  day,  you  may  give  a  mixture  of  bicarbonate  of  potash  not 
quite  saturated  with  citric  acid,  and  containing  small  doses  of  ipeca- 
cuanha wine,  if  the  stomach  be  not  extremely  irritable,  and  of  the 
tincture  of  hyoscyamus ;  the  value  of  which  last  medicine  as  a  seda- 
tive in  the  diseases  of  children  can  scarcely  be  too  highly  estimated. 
The  addition  of  a  little  syrup  of  mulberries  will  render  the  above  mix- 
ture extremely  palatable.1 

(No.  2.) 

1  R  Potassse  Bicarbonat. 
Acidi  Citrici,  aa.  gr.  xx. 
Vin.  Ipecac,  rr^xij. 
Trae.  Hyosc.  n^xviij. 
Syr.  Mori,  giij. 

Aqua?  destill.  gix.     M.     gij  6ta  quaque  hora. 
For  a  child  a  year  old. 

You  will  sometimes  meet  with  cases  of  cerebral  congestion  that 
appear  to  have  been  brought  on  by  exposure  to  the  heat  of  summer. 
In  such  cases  it  often  happens  that  the  bowels  are  not  constipated, 
but  somewhat  relaxed.  You  must  not,  however,  aim  at  checking  the 
diarrhoea  by  direct  astringents,  but  should  rather  pursue  an  alterative 
plan.  In  most  instances  there  is  irregularity  of  the  bowels  rather 
than  diarrhoea ;  the  child  having  five  or  six  unhealthy  motions,  for  the 
most  part  destitute  of  bile,  in  the  course  of  one  day,  and  passing  the 
succeeding  twenty-four  hours  without  any  evacuation  at  all.  In  such 
cases  you  will  find  the  treatment  I  have  just  indicated  very  useful. 
If  the  bowels  be  much  disturbed,  half-grain  or  grain  doses  of  Dover's 
powder  may  be  combined  with  the  mercurial  with  advantage. 

I  have  not  time  to  enter  into  more  minute  details  with  reference  to 
the  management  of  every  variety  of  active  cerebral  congestion,  but 
must  briefly  notice  those  cases  in  which  the  condition  exists  in  what 
may,  perhaps  not  improperly,  be  called  the  passive  state.  In  the 
paroxysms  of  hooping-cough  the  brain  becomes  congested  by  the  im- 
pediment to  the  return  of  the  blood  from  the  head :  and  cerebral  con- 
gestion is  induced  in  a  similar  manner  when  the  larynx  becomes  spas- 
modically closed  in  the  disease  known  by  the  name  of  Laryngismus 
Stridulus.  But  we  likewise  meet  with  cases  where  the  passive  succeeds 
to  the  active  form  of  cerebral  congestion,  or  becomes  more  or  less 
gradually  developed  out  of  some  disorder  of  the  abdominal  viscera : 
or,  lastly,  where  it  supervenes  towards  the  close  of  life  in  weakly 
children,  whose  vital  powers  have  at  length  become  too  feeble  to 
propel  the  blood. 

In  children  who  have  suffered  long  and  severely  from  hooping-cough, 
you  often  notice  a  general  lividity  of  the  face  and  lips,  a  puffed  and 
anxious  countenance,  and  the  child  makes  grievous  complaints  about 
its  head,  while  the  skin  is  moist  and  cool,  and  the  pulse  soft,  though 
frequent.  Many  of  these  symptoms  indicate  an  overloaded  state  of 
the  cerebral  veins ;  and  if  a  paroxysm  of  coughing  occur,  and  the 
circulation  be  thus  further  disturbed,  the  child  may  die  in  a  fit,  or  may 


44  PASSIVE  CONGESTION — 

sink  after  some  convulsive  seizure  into  a  state  of  coma,  which  sooner 
or  later  proves  fatal.  In  such  a  case  you  will  find  the  vessels  of  the 
brain  and  its  membranes  universally  gorged  with  black  blood,  the 
choroid  plexuses  of  a  deep  purple  colour,  and  more  bloody  points  than 
natural  will  present  themselves  on  a  section  of  the  brain  being  made. 
Both  the  symptoms  during  life,  and  the  appearances  after  death,  are 
only  a  rather  exaggerated  illustration  of  what  occurs  in  all  cases  of 
passive  congestion  of  the  brain.  It  is  not,  however,  always  easy  to 
explain  why  this  condition  comes  on.  Among  the  poor  you  often  find 
it  connected  with  general  disorder  of  the  digestive  organs,  and  occur- 
ring as  one  of  a  long  train  of  ills  induced  by  destitution  and  neglect. 
It  was  so  in  the  case  of  a  little  boy  four  months  old,  whom  I  saw  a 
years  ago.  His  parents  were  young  and  healthy  people,  but  they  had 
already  lost  three  children,  apparently  in  consequence  of  their  inhabit- 
ing one  of  those  narrow  courts  so  numerous  in  London,  into  which  the 
sun  never  shines,  and  where  young  children  pine  and  fade  like  tender 
plants  shut  up  in  a  cellar.  When  ten  weeks  old,  this  little  boy  was 
taken  with  pain  in  his  bowels  and  diarrhoea,  and  at  three  months  old 
he  began  to  suffer  from  fits,  which  came  on  daily,  sometimes  several 
times  a  day.  No  efficient  treatment  had  been  adopted  when  he  was 
brought  to  me.  He  was  then  as  large  as  most  children  of  his  age, 
and  by  no  means  emaciated ;  but  his  flesh  was  flabby,  his  face  unintel- 
ligent, puffed  and  livid,  his  head  hot,  the  veins  of  the  scalp  and  eyelids 
turgid,  the  eyes  prominent,  lustreless,  covered  by  mucus,  and  the  pupils 
not  acting  under  light.  He  lay  in  his  mother's  lap,  uttering  a  con- 
stant hoarse  moan;  his  head  thrown  rather  back,  and  in  incessant 
rotatory  motion ;  his  mouth  was  open,  his  tongue  red  and  parched,  and 
the  papillae  on  its  surface  were  very  prominent :  his  abdomen  was  rather 
full,  and  his  legs  were  constantly  drawn  up  towards  it.  He  vomited 
much :  his  bowels  were  open  three  or  four  times  a  day,  the  motions 
being  green  and  offensive ;  his  pulse  was  frequent,  but  without  power. 
In  this,  as  in  many  instances  of  passive  congestion  of  the  brain,  local 
depletion  was  resorted  to  at  first,  and,  benefit  resulting  from  it,  was 
repeated  more  than  once.  It  is  not,  however,  every  case  that  will 
admit  of  even  local  depletion,  which,  whenever  employed,  must  be 
practised  only  with  the  view  of  affording  relief  to  the  gorged  cerebral 
vessels,  not  with  the  idea  of  curing  the  patient  by  bleeding.  The 
greatest  attention  must  in  every  case  be  paid  to  diet  and  to  the  state 
of  the  bowels,  and  you  will  find  no  means  of  inducing  their  healthy 
action  better  than  the  employment  of  small  doses  of  mercury  and 
chalk  two  or  three  times  a  day.  If  the  child  be  not  weaned,  you  may 
find  it  desirable,  if  there  be  constant  sickness,  to  take  it  almost,  or 
entirely,  from  the  breast  for  a  day  or  two,  and  to  substitute  barley- 
water,  sugar  and  water,  or  a  weak  solution  of  isinglass,  with  the  addi- 
tion of  one-third  of  milk,  which  should  be  given  in  quantities  of  one 
or  two  spoonfuls  at  a  time  till  the  stomach  becomes  more  settled.  A 
stimulating  bath,  as  a  hot  salt-water  bath,  or  a  bath  into  which  a 
handful  of  mustard  has  been  put,  and  in  which  the  child  is  to  be  kept 
for  four  or  five  minutes,  night  and  morning,  will  often  be  found  a 
valuable  auxiliary  to  the  general  treatment,  as  well  as  very  useful,  if 


ITS   SYMPTOMS  AND   TREATMENT.  45 

combined  with  the  application  of  cold  to  the  head,  in  cutting  short  the 
convulsive  seizures. 

If  the  case  be  associated  with  much  diarrhoea  and  general  impair- 
ment of  nutrition,  the  extract  of  bark,  with  a  few  drops  of  sal  volatile, 
or  of  the  compound  tincture  of  bark,  should  be  given  two  or  three 
times  a  day,  and  you  should  not  let  the  head  symptoms  lead  you  to 
keep  the  child  on  a  low  diet.1     Remember,  too,  that  when  nutrition  is 

(No.  3.) 

1  R  Extr.  Cinchonae,  gj. 

Tree.  Cinch.  Co.  gij. 

Aquae  Carui,  gx.     M.     £j.  ter  quotidie  e  lacte. 
For  a  child  a  year  old.     The  taste  of  the  above  mixture  is  best  concealed  by  sweetening 
it,  and  mixing  it  with  twice  the  quantity  of  milk. 

much  impaired,  farinaceous  food  is  usually  not  well  digested;  you  must, 
therefore,  be  sparing  of  arrow-root,  and  give  milk  and  water,  or  milk 
and  water  with  isinglass,'  or  veal- tea.  If  the  broth  should  purge,  as  it 
sometimes  does,  the  white  decoction  of  Sydenham3  will  form  a  cheap 
substitute  for  isinglass.  As  the  child  improves,  the  ferrocitrate  of 
quinine  will  be  one  of  the  best  tonics  you  can  give,3  and  throughout 

(No.  4.) 

3  B  Syrupi  Quinse  Ferro-Citrat.  giss. 
Syrupi  Aurantii,  sjiiss. 
Aquae  Flor.  Aurantii,  ^j.     M.  gj.  ter  die. 
For  a  child  a  year  old. 

the  whole  progress  of  the  case  you  will  remember  the  tonic  influence 
of  pure  air ;  and  may  even  find  the  removal  to  a  healthier  spot  and 
purer  atmosphere  absolutely  necessary  to  the  recovery  of  your  patient. 
Lastly,  I  will  just  allude  to  the  head  symptoms  that  sometimes  for  a 
few  days  precede  death  in  children  who  have  been  long  ill.  You  may 
in  such  cases  find  the  vessels  of  the  brain  turgid,  and  be  disposed  to 
reproach  yourselves  for  not  having  adoped  active'  treatment.  Such 
self-reproach  would  be  unmerited ;  the  streams  have  stagnated,  because 
the  vital  powers  were  all  too  feeble  to  keep  them  in  motion. 

2  This,  the  Decoction  Blanche  of  the  French  Pharmacopoeia,  is  made  by  boiling  half 
an  ounce  of  hartshorn  shavings,  and  the  inside  of  one  French  roll,  in  three  pints  of 
water,  till  reduced  to  two ;  when  it  may  be  sweetened,  and  given  either  alone  or  with 
the  addition  of  one  part  of  milk. 


46        CEREBRAL   H-EMORRHAGE   ONE  CAUSE  Or  INFANTILE  ASPHYXIA. 


LECTURE    IV. 

Cerebral  Hemorrhage. — The  rupture  of  any  large  vessel  in  childhood  very  rare,  but 
effusion  of  blood  into  arachnoid  frequent — reasons  for  its  especial  frequency  in  new- 
born infants — its  symptoms  and  treatment. — Blood  sometimes  effused  external  to  the 
skull  in  new-born  infants. — Cephalhematoma,  its  characters,  changes  in  the  effused 
blood,  and  process  of  cure — its  treatment. — Haemorrhage  into  arachnoid  in  childhood 
— changes  in  the  effused  blood — obscurity  of  the  symptoms — occurs  sometimes  in  very 
feeble  children,  or  in  connection  with  changes  in  the  blood — illustrative  cases. — 
Haemorrhage  into  cerebral  substance  in  childhood  extremely  rare — cases  in  illustra- 
tion of  its  causes  and  symptoms — capillary  haemorrhage  in  connection  with  tubercle 
in  the  brain. 

When  we  last  met,  I  called  your  attention  to  the  very  important 
consequences  that  may  result  from  the  vessels  of  the  brain  becoming 
overloaded  with  blood.  I  pointed  out  to  you  a  train  of  symptoms, 
rising  in  severity,  from  mere  pain  or  heaviness  of  the  head,  to  convul- 
sions or  coma,  according  to  the  degree  of  the  cerebral  congestion ;  and 
told  you  that  death  itself  might  take  place,  without  any  mischief 
being  discoverable,  afterwards,  more  serious  than  a  general  turgesceuce 
of  the  vessels  of  the  brain  and  its  membranes.  Simple  apoplexy,  indeed, 
is  by  no  means  rare  in  childhood,  and  the  knowledge  of  this  fact  may 
furnish  encouragement  to  us  in  cases  where  the  symptoms  of  present 
danger  are  most  alarming.  We  may  hope,  that  if  the  instant  peril 
can  be  averted,  the  blood,  which  has  not  burst  its  vessels,  will  flow 
again  tranquilly  through  them,  and  the  functions  of  life  once  more  go 
on  in  their  wonted  course.  In  the  adult  we  could  scarcely  indulge  such 
an  expectation,  for  the  import  of  apoplectic  symptoms  is  generally  far 
more  serious.  If  the  patient  die,  we  look  for,  and  seldom  fail  to  find, 
blood  poured  out  into  the  brain,  compressing  its  substance,  and  lace- 
rating the  delicate  fibres  along  which  the  nervous  influence  travels.  Or, 
even  should  he  survive,  it  often  is  to  pass  through  a  tedious  convales- 
cence, with  palsy,  and  weakened  senses,  and  impaired  mental  powers, — 
the  sad  and  standing  evidence  of  the  grievous  injury  which^he  brain 
has  sustained. 

You  may  naturally  inquire  how  it  happens  that  in  the  child,  the  very 
structure  of  whose  skull  favours  the  occurrence  of  cerebral  congestion, 
haemorrhage  into  the  brain  is  comparatively  so  rare :  while  in  the 
adult,  whose  unyielding  cranium  and  firmer  brain  tend  to  check  con- 
gestion, the  extravasation  of  blood  into  its  substance  takes  place  so 
often?  The  changes  which  advancing  age  induces  in  the  structure  of 
the  cerebral  vessels  are  probably  the  chief  cause  of  this  difference.  In 
early  life,  the  arteries  are  yielding,  and  admit  of  being  greatly  dis- 
tended without  giving  way :  but  in  the  course  of  years  they  lose  their 
elasticity,  their  calibre  becomes  diminished  and  unequal,  and  their 
coats  grow  brittle  by  the  deposit  of  a  cartilaginous  or  earthy  matter  in 
their  tissue. 

But  though  the  larger  arterial  trunks  withstand  the  constantly  recur- 
ring variations  in  the  cerebral  circulation  during  infancy  and  child- 


CEREBRAL   HEMORRHAGE   ONE   CAUSE   OF   INFANTILE   ASPHYXIA.        47 

hood,  the  smaller  and  more  delicate  vessels  of  the  brain  are  very  liable 
to  give  way,  and  capillary  hemorrhage,  or  haemorrhage  by  exhalation, 
as  it  has  been  often,  though  incorrectly,  termed,  takes  place  with 
greater  frequency  than  in  adult  age. 

All  periods  of  childhood  are  not  equally  exposed  to  this  accident, 
but  it  is  oftenest  met  with  immediately  after  birth ;  and  no  circum- 
stances can  be  imagined  more  favourable  to  its  occurrence  than  those 
which  then  concur  to  produce  it.  The  head  of  /the  infant  has  been 
subjected  to  severe  and  long-continued  pressure  during  its  progress 
through  the  mother's  pelvis ;  immediately  on  its  birth,  the  course  of 
the  circulation  is  altogether  changed,  and  should  any  difficulty  occur  in 
the  establishment  of  the  new  function  of  respiration,  a  long  time  will 
elapse  before  the  blood  flows  freely  through  its  unaccustomed  channels. 
!No  one  will  wonder  that  death  should  frequently  take  place  during  this 
transition  to  a  new  kind  of  existence.  The  tumid  scalp  and  livid  face 
of  many  a  still-born  child  point  to  one  of  its  most  important  causes, 
since  they  are  but  the  measure  of  that  extreme  congestion  of  the 
vessels  within  the  skull  that  has  at  length  ended  in  a  fatal  effusion  of 
blood  upon  the  surface  of  the  brain. 

There  would  be  reason  to  fear  that  this  occurrence  had  taken  place, 
if  an  infant,  when  born,  were  to  present  great  lividity  of  the  surface, 
and  especially  of  the  face;  and  if  the  heart  were  to  beat  feebly,  and  at 
long  intervals,  although  the  pulsations  of  the  cord  were  slow  and  faint, 
or  had  altogether  ceased.  Under  these  circumstances,  death  sometimes 
takes  place  without  any  effort  at  respiration  being  made,  the  beatings 
of  the  heart  growing  feebler  and  fewer  till  they  entirely  cease ;  but  at 
other  times  the  child  breathes  irregularly,  imperfectly,  and  at  long 
intervals.  The  hands  are  generally  clenched,  and  spasmodic  twitchings 
are  of  frequent  occurrence  about  the  face,  or  these  twitchings  are  more 
general  and  more  severe,  and  amount  almost  to  an  attack  of  convul- 
sions. The  symptoms,  however,  are  by  no  means  uniform,  and 
probably  are  in  some  degree  modified  by  variations  in  the  seat  as  well 
as  in  the  quantity  of  the  effusion ;  for  it  sometimes  happens,  even  in 
cases  where  a  very  large  quantity  of  blood  has  been  poured  out  into 
the  arachnoid  cavity,  that  the  breathing  is  little  or  not  at  all  disturbed, 
and  after  living  for  a  few  hours  in  a  state  of  weakness  and  torpor,  with 
chilliness  of  the  whole  surface,  the  child  dies  without  any  sign  of 
convulsion. 

Instances  of  this  form  of  asphyxia  will  be  sure  to  come  under  the 
notice  of  those  of  you  who  engage  in  midwifery  practice.  I  need 
hardly  remind  you  that  the  first  indication  to  fulfil  in  their  treatment 
is  to  relieve  the  overloaded  vessels  of  the  brain,  by  allowing  of  the 
escape  of  half  an  ounce  or  an  ounce  of  blood  from  the  divided  umbilical 
cord.  When  the  diminished  lividity  of  the  surface  shows  that  this  end 
has  been  attained,  the  cord  should  be  tied,  and  the  child  may  now  be 
plunged  for  a  minute  or  two  in  a  hot  bath  at  100°  or  102°  ;  but  pro- 
longed immersion  in  a  bath  at  a  less  elevated  temperature  is  likely  to 
depress  the  nervous  energy.  While  the  body  is  in  the  bath,  cold  waxer 
may  be  dashed  rather  smartly  on  the  face  or  chest,  by  which  means  the 
inspiratory  muscles  are  often  excited  to  action.     If,  however,  the  child 


48  CEPHALHEMATOMA. 

do  not  soon  begin  to  breathe,  you  must  not  continue  too  long  the  use  of 
these  or  of  other  subsidiary  measures,  such  as  the  application  of  am- 
monia to  the  nostrils,  tickling  the  throat  or  nares  with  a  feather,  &c. 
for  you  would  thus  fruitlessly  consume  that  time  which  Would  be  much 
more  usefully  spent  in  making  a  persevering  trial  of  artificial  respiration. 

If  no  occurrence  have  taken  place  more  serious  than  a  very  great 
degree  of  congestion  of  the  cerebral  vessels,  you  will  generally  succeed, 
by  the  use  of  these  means,  in  restoring  the  child.  Often,  however,  it 
will  happen  that  your  attempts  at  resuscitation  will  fail  completely,  or 
that  after  breathing  imperfectly  for  a  few  hours  without  having  ever 
seemed  thoroughly  restored,  the  child  will  die,  and  you  will  then  find 
blood  poured  out  into  the  cavity  of  the  arachnoid.  The  extravasation 
is  sometimes  limited  to  the  neighbourhood  of  the  cerebellum,  but  at 
other  times  it  covers  a  considerable  part  of  the  convex  surface  of  the 
brain,  and  even  occupies  the  spinal  canal ;  as  you  see  in  this  by  no 
means  exaggerated  representation  of  a  case  of  infantile  apoplexy  in 
Cruveilhier's  great  work  on  Morbid  Anatomy.1 

It  fortunately  happens  that  the  overcharged  vessels  of  the  head  in 
the  new-born  infant  do  no.t  always  relieve  themselves  by  pouring  out 
blood  within  the  skull,  but  sometimes  the  capillaries  of  the  scalp  give 
way,  and  blood  is  extravasated  into  its  tissue ;  or,  at  other  times,  the 
effusion  of  blood  takes  place  between  the  bone  and  pericranium. 
When  this  last  accident  occurs,  it  often  gives  rise  to  the  formation  of  a 
tumor  upon  the  head,  that  presents  peculiarities  sufficient  to  call  for 
some  notice. 

This  tumor  (cephalcematoma,  as  it  has  been  called,  from  xj$a%ti  head, 
and  difiat^/.iay  from  a*w<*  blood)  makes  its  appearance  within  forty- 
eight  hours  after  birth — often  much  sooner —  on  one  or  other  parietal 
bone,  most  frequently  on  the  right,  as  a  circumscribed,  soft,  elastic, 
slightly  fluctuating,  painless  swelling,  beneath  the  unchanged  integu- 
ment. On  a  careful  examination,  it  is  generally  felt  to  be  bounded  by 
a  firm,  apparently  osseous  ridge,  which  usually  encircles  it  completely, 
though  more  distinct  at  one  part  than  another.  On  passing  the  finger 
over  the  summit  of  this  ridge,  and  down  towards  the  base  of  the  tumor, 
the  impression  is  at  once  conveyed  of  the  parietes  of  the  skull  being 
deficient  at  this  point,  and  of  the  ridge  being  the  edge  of  a  hole  in  the 
bone.  When  first  discovered,  the  tumor  is  usually  small,  but  increases, 
in  the  course  of  two  or  three  days,  from  the  size  of  a  marble  to  that  of 
a  chestnut,  or  of  half  a  hen's  egg.  As  it  grows  larger,  it  generally 
becomes  tenser,  but  still  seems  to  cause  no  pain,  and  the  child's  health 
continues  good.  After  it  has  attained  its  full  size,  it  often  remains 
stationary  for  a  few  days,  and  during  this  time  a  gradual  increase  in 
the  distinctness  of  the  ring  which  surrounds  it  is  the  only  change  that  it 
undergoes.  A  slight  diminution  in  the  size  of  the  tumor  at  length 
becomes 'perceptible,  and  then  it  slowly  disappears,  though  its  removal 
occupies  a  month,  six  weeks,  or  more,  and  a  slight  elevation  of  the 
skull  at  the  point  where  it  was  situated  sometimes  remains  even  longer. 
The  centre  of  the  tumor  generally  retains  its  soft  and  fluctuating  character 

1  Anatomie  Pathologique,  liv.  xv.  pi.  1. 


CHANGES   IN   THE   EFFUSED   BLOOD.  49 

nearly  to  the  last,  but  occasionally  it  loses  this,  and  communicates  to 
the  finger  a  sensation  of  crackling  such  as  we  should  experience  if  we 
pressed  on  a  piece  of  tinsel. 

Although  once  the  subject  of  much  difference  of  opinion,  the  mode  of 
formation  of  these  tumors,  and  the  nature  of  the  changes  they 
undergo,  are  now  tolerably  well  understood.  The  edges  of  the  os  uteri, 
compressing  the  fcetal  skull  during  labour,  just  as,  in  this  engraving,1 
the  hands  are  represented  compressing  it,  often  produce  an  effect 
similar  to  that  which  you  see  depicted  here,  and  occasion  an  oozing  of 
blood  from  its  surface.  The  quantity  of  blood  thus  poured  out  is 
usually  small,  and  is  then  speedily  absorbed,  without  having  at  any 
time  produced  a  perceptible  swelling.  If,  however,  it  be  more  consid- 
erable, a  tumor  is  formed  on  the  exterior  of  the  skull,  and  this  tumor 
may  continue  to  enlarge  for  some  time  after  birth,  owing,  possibly,  to 
the  influence  of  causes  calculated  to  keep  up  a  congested  state  of  the 
brain,  and  to  favour  the  effusion  of  blood.2 

The  blood  thus  effused  speedily  coagulates,  and  the  edge  of  the 
coagulum  sometimes  conveys  to  the  finger  an  indistinct  sensation  of  a 
raised  border  surrounding  the  tumor.  The  elevated  ring  that  is  after- 
wards plainly  felt  circumscribing  it,  is,  however,  mainly  the  result  of  a 
reparative  process,  in  the  course  of  which  a  fibrinous  exudation  is  poured 
out  over  that  part  of  the  skull  whence  the  pericranium  has  been  detached, 
and  is  heaped  up  in  great  abundance  just  where  the  bone  and  its  invest- 
ing membrane  come  into  apposition.  This  is  proved  to  be  its  real 
source,  by  the  circumstance  that  the  ring  becomes  much  more  evident 
after  the  absorption  of  the  blood  has  commenced,  than  it  is  at  first 
while  in  those  cases  where  the  effusion  of  blood  has  been  very  considerable , 
no  ring  is  perceptible  during  life,  and  it  is  found  after  death  that  scarcely 
any  attempt  at  reparation  has  been  made,  and  that  the  fibrinous  exudation 
is  very  scanty,  or  altogether  absent. 

This  exudation  is  generally  absorbed  in  course  of  time,  but  sometimes 
a  process  of  ossification  is  set  up  in  it :  the  fibrinous  ring  becomes 
converted  into  an  osseous  ridge,  and  that  part  of  the  cranium  over  which 
the  blood  had  been  poured  out  is  roughened  by  the  formation  of  new 
bone  upon  its  surface.  The  meaning  of  the  appearances  thus  produced 
was  long  misunderstood,  and  they  were  thought  to  be  owing  to  a  process 
of  destruction,  not  to  one  of  cure.  The  roughened  surface  of  the  skull 
was  looked  on  as  the  result  of  ulceration  by  which  its  outer  table  had  at 
one  part  been  destroyed,  and  the  bony  ridge  around  it  was  supposed  to 
be  the  edge  of  that  part  of  the  outer  table  to  which  the  disease  had  not 
yet  extended.  The  real  nature  of  these  changes  was  extremely  well 
exemplified  in  a  very  remarkable  case  that  came  under  my  notice,  in  which 
blood  was  effused  between  the  skull  and  dura  mater,  as  well  as  between 

1  In  Valleix's  Clinique  des  Maladies  des  Enfants  Nouveau-ne*s,  Paris,  1839,  planche 
i.  fig.  2. 

2  The  various  questions  relating  to  the  mode  of  formation  of  these  tumors  are  fully 
discussed  by  Feist,  Ueber  die  Kopfblutgeschwulst  der*  Neugebornen,  4to.  Mainz,  1839 
and  by  Burchard,  De  Tumore  Cranii  recens  natorum  sanguineo,  4to.  Vratislaviae,  1837 
where  are  likewise  mentioned  various  exceptional  cases  in  which  the  swelling  formed 
on  the  parietal  bone  that  had  been  directed  towards  the  sacrum,  and  not,  as  is  usual, 
on  the  bone  which  had  presented  during  labour. 

4 


50  CEPHALHEMATOMA — ITS   TREATMENT. 

it  and  the  pericranium.*  This  drawing  shews  the  processes  of  cure  in 
progress.  First,  however,  you  may  notice  the  perfect  smoothness  of  the 
inner  surface  of  the  bone,  in  order  to  display  which  the  edge  of  the  clot  is 
raised.  Its  outer  as  well  as  its  inner  investment  had  been  detached 
from  this  portion  of  the  skull  by  the  effusion  of  blood  beneath  them,  and 
the  bone  continues  unroughened,  because  an  attempt  at  reparation  was 
impossible  here.  At  the  edge  of  the  clot,  the  dura  mater  and  the  bone 
come  again  into  contact,  and  nature  has  here  begun  the  cure.  New  bone 
has  been  deposited,  and  an  osseous  ridge  has  been  formed  precisely 
similar  to  that  which  in  so  many  instances  surrounds  the  external  effusion. 
Nor  is  this  all ;  but  bony  plates  are  beginning  to  be  deposited  between 
the  layers  of  the  dura  mater;  exemplifying  the  manner  in  which,  when 
blood  has  been  poured  out  beneath  the  pericranium,  that  membrane 
sometimes  becomes  ossified,  and  accounting  for  the  crackling  sensation 
that  in  these  cases  is  felt  on  pressing  the  tumor. 

The  characteristics  of  these  tumors  are  so  well  marked,  that  they  are 
not  likely  to  be  confounded  with  swellings  of  the  scalp  produced  by  any 
other  cause.  A  hernia  of  the  brain,  indeed,  may  present  some  resem- 
blance to  them,  since  it  forms  a  soft  painless  tumor,  unattended  by  dis- 
colouration of  the  integuments ;  and  the  edges  of  the  aperture  in  the 
bone  through  which  the  brain  protrudes  may  easily  be  taken  for  the  ring 
which  surrounds  an  effusion  of  blood  beneath  the  pericranium.  Inde- 
pendently, however,  of  the  pulsating  character  of  the  swelling  formed  by 
hernia  of  the  brain,  its  situation  at  one  of  the  fontanelles,  probably  the 
posterior,  or  in  the  course  of  One  of  the  sutures,  will  generally  distinguish 
it  sufficiently  from  these  sanguineous  tumors,  which  are  almost  always 
seated  on  the  parietal  bone,  and  near  to  its  protuberance. 

While  the  nature  of  this  affection  was  ill  understood,  many  prac- 
titioners regarded  it  as  of  very  serious  import,  and  thought  that  its  cure 
could  be  effected  only  by  making  a  free  incision  into  the  tumor,  and 
emptying  it  of  the  effused  blood,  or  else  by  applying  caustic  to  its  surface, 
with  the  view  of  exciting  suppuration  within  it.  There  is,  however,  no 
real  necessity  for  these  severe  measures,  which  appear  in  not  a  few 
instances  to  have  caused  the  death  of  the  child ;  for  the  blood  will  in  the 
course  of  a  few  weeks  be  absorbed,  and  the  tumor  diminish  and  disappear 
of  its  own  accord.  The  great  difficulty,  indeed,  that  you  will  encounter 
will  consist  in  persuading  the  parents  to  let  the  swelling  alone,  and  to 
wait  till  time  effects  its  removal.  While,  however,  the  affection  generally 
requires  no  treatment,  and  is  not  attended  by  any  danger,  it  is  yet  right 
to  bear  in  mind  the  possibility  of  internal  as  well  as  external  effusion 
having  taken  place  ;  in  which  case,  as  happened  in  an  instance  that  came 
under  my  notice,  the  sudden  increase  of  the  former  may  be  followed  by 
apoplectic  symptoms,  and  death. 

Perhaps  I  may  be  pardoned  if  I  digress  for  a  moment  to  notice  the 
occasional  pouring  out  of  blood  beneath  the  occipito-frontalis,  or  temporal 
muscle  in  children  as  the  result  of  a  blow  on  the  head.  Unlike  a  bruise, 
this  effusion  does  not  always  take  place  at  the  precise  spot  where  the 

l  A  description  of  this  case  will  be  found  at  p.  397  of  vol.  xxviii.  of  the  Medico- 
Chirurgical  Transactions. 


HEMORRHAGE   INTO   THE   ARACHNOID.  51 

injury  was  inflicted,  but  the  greater  size  of  the  vessels  that  traverse  the 
skull  at  the  side  seems  to  be  the  reason  why  a  shock,  such  as  a  fall  on 
the  occiput,  is  sometimes  succeeded  by  the  formation  of  a  tumor  of  this 
kind  at  the  side  of  the  head,  and  not  at  the  part  which  received  the  blow. 
It  has  twice  come  under  my  notice  under  these  circumstances.  The 
tumor  thus  formed  is  soft,  painless,  and  fluctuating,  and  its  size  at  first 
increases  very  rapidly,  but  the  integuments  covering  it  are  neither  hot 
nor  discoloured.  It  is  not  surrounded  by  so  well  defined  a  ring  as 
circumscribes  the  swelling  formed  by  the  effusion  of  blood  beneath  the 
pericranium  ;  the  ridge  is  imperfect,  its  edge  is  much  less  sharp,  and  it  is 
often  to  be  felt  nowhere  except  near  to  the  insertion  of  the  temporal 
muscle. 

In  this  as  in  the  other  case  nature  herself  is  usually  fully  equal  to 
the  removal  of  the  blood,  and  the  consequent  dispersion  of  the 
swelling. 

Cerebral  haemorrhage,  though  at  no  other  time  so  frequent  as  imme- 
diately after  birth,  may  occur  at  any  period  of  subsequent  childhood, 
under  the  influence  of  causes  that  favour  congestion  of  the  brain,  or 
even  independently  of  any  cause  that  we  can  discover.  The  hemor- 
rhage still  takes  place  almost  invariably  into  the  arachnoid  cavity,  and 
blood  is  sometimes  poured  out  there  in  very  large  quantity,  but  the 
accident  is  neither  so  invariably  nor  so  speedily  fatal  as  in  the  new- 
born infant. 

If  death  should  follow  very  soon  after  the  occurrence  of  the  effusion, 
the  blood  is  found  unchanged,  forming  a  more  or  less  extensive  layer 
upon  the  convex  surface  of  the  brain,  and  extending  downwards  and 
backwards  towards  the  base  of  the  organ,  but  seldom  situated  at  its 
anterior  part  unless  the  haemorrhage  have  been  unusually  profuse.  If 
life  be  prolonged,  the  clot  speedily  separates  into  serum  and  crassa- 
mentum,  and  a  series  of  changes  commences  in  the  latter,  the  effect  of 
which  is  to  deprive  it  of  its  colouring  matter,  and  to  convert  it,  in 
course  of  time,  into  a  delicate  false  membrane,  which  lies  in  close  appo- 
sition with  the  parietal  arachnoid.  This  transformation  may  sometimes 
be  observed  while  in  course  of  progress,  and  a  central  clot  may  then 
be  seen  gradually  losing  itself  in  a  membrane  that  grows  more  and 
more  delicate  towards  its  periphery.  If,  as  occasionally  happens, 
successive  effusions  of  blood  take  place  at  somewhat  distant  intervals, 
this  membrane  may  become  thick  and  firm,  and  may  even  present  a 
pearly  lustre  ;  which  circumstance  has  led  some  observers  into  the 
error  of  attributing  the  appearance  to  alteration  and  thickening  of  the 
dura  mater.  The  amount  of  the  original  effusion  has  much  to  do  with 
the  rapidity  of  the  changes  in  the  clot.  If  the  effusion  were  but  incon- 
siderable, the  serum  of  the  blood  soon  becomes  absorbed,  and  no  other 
trace  of  the  occurrence  remains  than  the  false  membrane  lining  a 
portion  of  the  arachnoid.  If  the  haemorrhage  were  at  all  abundant, 
the  reddish  serum  will,  even  after  the  lapse  of  a  considerable  time,  be 
very  evident  on  opening  the  sac  of  the  arachnoid,  and  some  of  it  will 
probably  be  found  entangled  in  the  substance  of  the  clot.  By  degrees 
the  serum  loses  its  colour,  but  its  quantity  may  still  continue  for  a  long 
time  undiminished,  or  the  efforts  of  nature  may  even  entirely  fail  to 


52  OBSCURITY   OP   THE    SYMPTOMS. 

accomplish  its  absorption.  The  fluid  in  such  cases  is  either  simply 
contained  within  the  arachnoid  cavity,  or,  having  remained  inclosed 
within  the  clot  during  the  changes  which  it  underwent,  appears  at 
length  to  be  situated  within  a  delicate  cyst  or  shut  sac.  If  the  haemor- 
rhage, in  the  first  instance,  were  very  considerable,  or  if  it  were  to 
recur  two  or  three  times,  the  yielding  cranium  of  the  child  will  enlarge, 
the  head  will  alter  in  form,  and  the  case  will  assume  many  of  the 
characters  of  chronic  hydrocephalus.1 

All  writers,  even  those  who,  like  MM.  Rilliet  and  Barthez,  have 
thrown  the  most  light  on  the  anatomy  and  pathology  of  cerebral 
haemorrhage  in  the  child,  concur  in  representing  its  symptoms  as  ex- 
tremely obscure.  Paralysis,  which,  in  the  grown  person,  is  one  of  the 
most  frequent  results  of  the  escape  of  blood  from  the  cerebral  vessels, 
is  so  rare  in  the  child  that  it  was  observed  by  M.  Legendre2  only  in 
one  out  of  nine  cases,  and  by  MM.  Rilliet  and  Barthez3  in  one  out  of 
seventeen  cases.  This  peculiarity  is  doubtless  in  great  measure 
accounted  for  by  the  circumstance  of  the  blood  being  almost  always 
poured  out  into  the  cavity  of  the  arachnoid,  so  that  the  pressure  which 
it  exerts  on  the  brain  is  generally  diffused  over  the  surface  of  the 
organ,  and  is  no  where  very  considerable. 

The  absence  of  paralytic  symptoms,  however,  is  not  the  sole  cause 
of  the  obscurity  of  these  cases,  but  the  indications  of  cerebral  distur- 
bance by  which  they  are  attended  very  greatly  in  kind  as  well  as  in 
degree.  The  sudden  occurrence  of  violent  convulsions,  and  their 
frequent  return,  alternating  with  spasmodic  contraction  of  the  fingers 
and  toes  in  the  intervals,  appear  to  be  the  most  frequent  indications 
of  the  effusion  of  blood  upon  the  surface  of  the  brain.  I  need  not  say, 
however,  that  such  symptoms  taken  alone  would  by  no  means  justify 
you  in  inferring  that  effusion  of  blood  had  taken  place.  Many  circum- 
stances having  reference  to  the  previous  history  of  the  child,  as  well  as 
to  its  present  condition,  must  be  taken  into  account  in  forming  a 
diagnosis.  Haemorrhage  into  the  arachnoid  cavity  is  most  frequent  in 
early  childhood, — symptoms  such  as  have  been  enumerated  then  would 
acquire  additional  diagnostic  importance  in  proportion  to  the  tender 
age  of  the  child  in  whom  they  occurred.  The  probability  of  their 
betokening  this  accident  would  be  still  further  strengthened  if  the  child 
who  experienced  them  had  previously  suffered  from  frequent  attacks  of 
cerebral  congestion,  or  had  been  recently  exposed  to  the  sun  without 
proper  covering  to  the  head  ;  or  had  been  placed  in  other  circumstances 
calculated  to  favour  determination  of  blood  to  the  head. 

The  popular  notion  that  associates  the  idea  of  rude  health  and 
general  plethora  with  the  occurrence  of  apoplexy  in  the  adult,  is  in 
many  instances  altogether  fallacious.     In  the  case  of  the  child  it  has 

1  Not  having  had  the  opportunity  of  observing  the  whole  series  of  changes  said  to 
take  place  in  blood  effused  into  the  sac  of  the  arachnoid,  I  have  chiefly  followed  the 
account  given  by  MM.  Rilliet  and  Barthez,  in  their  Traite"  des  Maladies  des  Enfans, 
vol.  ii.  pp.  32  to  42. 

g  Recherches  Anatomo-Pathologiques  sur  quclques  Maladies  de  l'Enfance,  8vo.  Paris, 
1846,  p.  130. 

3  Lib.  cit.,  p.  43. 


ILLUSTRATIVE   CASES.  53 

still  less  foundation,  since  the  effusion  of  blood  upon  the  brain  occurs 
much  more  frequently  in  weakly  children  than  in  such  as  are  robust. 
There  seems  to  be  reason,  indeed,  for  supposing  that  the  haemorrhage 
is  sometimes  of  a  purely  passive  character,  and  dependant  on  an  altered 
state  of  the  blood.  I  will  rekte  to  you  a  case  or  two  as  illustrations  of 
this  cachectic  form  of  cerebral  haemorrhage. 

Some  years  ago,  I  saw  a  little  boy,  five  weeks  old,  the  child  of  healthy 
parents,  and  who  had  been  perfectly  well  for  the  first  fortnight  after  his 
birth :  he  then,  without  any  evident  cause,  grew  drowsy,  and  vomited 
often,  and  his  skin  became  quite  jaundiced.  His  abdomen  at  this  time 
was  large  and  hard,  and  he  cried  when  pressure  was  made  on  the  right 
hypochondrium  :  these  symptoms  still  continued  when  he  was  brought 
to  me.  A  leech  now  applied  on  the  right  side  drew  a  good  deal  of  blood, 
and  the  haemorrhage  was  stopped  with  difficulty  ;  the  bowels,  previously 
constipated,  were  acted  on  by  small  doses  of  calomel  and  castor  oil,  and 
in  three  days  the  child  lost  the  yellow  tinge  of  his  skin,  became  cheerful, 
and  seemed  much  better.  He  was  now,  however,  on  the  18th  of  July, 
suddenly  seized  with  hurried  respiration  and  great  depression,  soon  fol- 
lowed by  violent  convulsions,  during  which  he  screamed  aloud.  At  the 
same  time  it  was  observed  that  his  left  hand  had  begun  to  swell,  and  to 
put  on  a  livid  hue,  and  on  the  20th,  the  right  hand  also  became  ©edema- 
tous. His  whole  surface  grew  quite  sallow,  and,  on  the  day  before  he 
died,  the  oedema  of  the  left  hand  had  much  increased ;  the  livor  had 
become  considerably  deeper,  and  there  were  small  spots  of  extravasatecl 
blood  over  each  knuckle.  The  right  elbow  was  slightly  livid;  the  right 
hand  much  swollen,  but  of  its  natural  colour ;  and  a  small  black  spot 
had  appeared  under  the  chin,  corresponding  to  the  knot  of  the  cap-string. 
The  fits  recurred  very  frequently,  the  child  in  the  intervals  lying  quite 
still ;  the  pupils  were  contracted,  and  the  condition  seemed  to  be  one  of 
extreme  exhaustion  rather  than  of  coma.  On  the  20th,  the  power  of 
deglutition  was  lost,  and  after  several  returns  of  less  violent  convulsions, 
the  child  died  at  9  A.  M.  on  July  21st ;  about  sixty  hours  after  the 
occurrence  of  the  first  fit. 

The  sinuses  of  the  brain  were  full  of  fluid  blood;  a  black  coagulum, 
three  or  four  lines  thick,  covered  the  whole  posterior  part  of  both  hemi- 
spheres, extending  from  the  posterior  third  of  the  parietal  bones,  occu- 
pying the  whole  concha  of  the  occipital  bone,  and  reaching  along  the 
base  of  the  skull  to  the  foramen  magnum.  A  little  blood- was  likewise 
effused  about  the  anterior  part  of  the  base  of  the  brain,  though  the 
quantity  was  very  small  in  comparison  with  what  was  found  at  its 
posterior  part.  The  substance  of  the  brain  was  very  pale,  and  all  the 
organs  of  the  body  were  anaemic,  except  the  liver,  which  was  gorged 
with  fluid  blood,  while  the  heart  was  quite  empty.  The  ductus  arte- 
riosus was  closed,  the  foramen  ovale  admitted  a  probe  with  ease,  the 
ductus  venosus  admitted  one  with  difficulty. 

Another  instance  has  since  then  come  under  my  notice,  in  which 
passive  haemorrhage  took  place  into  the  arachnoid  in  a  child  exhausted 
by  long-continued  illness,  the  effects  of  which  were  aggravated  by  poverty 
and  want.  From  the  age  of  two  to  that  of  five  months  the  child  had 
been  under  my  care  in  consequence  of  frequent  attacks  of  haematemesis 


54  HEMORRHAGE   INTO   THE   SUBSTANCE   OF   THE   BRAIN. 

and  purging  of  blood,  and  though  his  health  afterwards  improved,  yet  he 
never  became  strong,  and  his  evacuations  were  almost  always  white,  and 
deficient  in  bile.  After  he  was  weaned,  the  coarse  food  which  his  indi- 
gent parents  gave  him  did  not  nourish  him;  he  lost  flesh  and  strength, 
and  when  almost  three  years  old  was  puny  and  emaciated.  Three  days 
before  his  death  an  attack  of  diarrhoea  came  on,  which  induced  great 
exhaustion;  and  while  suffering  from  this  affection,  he  suddenly  became 
comatose,  cold,  and  almost  pulseless,  and  his  breathing  became  so  slow 
that  he  inspired  only  four  or  five  times  in  a  minute.  In  this  state  he 
lay  for  twenty-four  hours,  and  then  died  quietly.  Nearly  six  ounces  of 
dark  coagulated  blood  were  found  in  the  sac  of  the  arachnoid,  over  the 
right  hemisphere  of  the  brain;  a  little  blood  was  likewise  effused  beneath 
the  arachnoid,  and  there  was  a  very  small  clot  in  the  lower  and  front 
part  of  the  right  middle  lobe  of  the  brain,  but  no  ruptured  vessels  could 
be  perceived.  Great  anaemia  of  every  organ,  and  a  state  of  extreme 
attenuation  of  the  walls  of  the  heart,  were  the  only  other  remarkable 
appearances. 

Haemorrhage  into  the  substance  of  the  brain,  though  extremely  rare  in 
infancy  and  childhood,  does  sometimes  occur,  and  then  gives  rise  to 
appearances  similar  to  those  with  which  we  are  familiar  in  the  adult. 
Death,  however,  usually  takes  place  too  speedily  in  these  cases  for  any 
of  those  changes  to  occur  in  the  apoplectic  effusions  which  are  often 
observed  in  the  adult,  and  which  betoken  the  advance  that  nature  has 
made  in  her  efforts  to  repair  the  injury  of  the  brain. 

I  have  only  twice  met  with  distinct  extravasation  of  blood  into  the 
substance  of  the  brain  in  children.  In  the  first  case,  that  of  a  little  girl 
11  months  old,  the  occurrence  was  evidently  due  to  the  impediment  to 
the  circulation  through  the  brain  produced  by  an  attack  of  inflammation 
of  the  sinuses  of  the  dura  mater.  In  addition  to  other  appearances 
which  I  shall  describe  in  a  future  lecture,  there  was  great  venous  conges- 
tion of  the  membranes  covering  the  middle  lobe  of  the  left  hemisphere 
of  the  brain,  and  the  cerebral  veins  were  distended  with  coagula,  and 
their  coats  were  thickened.  At  the  anterior  part  of  the  lower  surface  of 
the  left  middle  lobe  of  the  brain  there  were  four  apoplectic  effusions,  in 
all  of  which  the  blood  still  retained  its  natural  colour,  and  each  effusion 
was  situated  close  to  an  obliterated  and  distended  vein.  The  largest 
clot  extended  for  an  inch  into  the  substance  of  the  brain,  the  others 
were  of  smaller  dimensions.  Head  symptoms,  as  might  be  expected,  had 
existed  in  this  little  child  for  a  long  time  before  her  death.  The  occur- 
rence of  the  effusion  was  probably  synchronous  with  a  sudden  attack  of 
extreme  faintness  that  came  on  forty-eight  hours  before  she  died,  and 
from  which  she  never  completely  rallied. 

The  other  instance  of  hsemorrhage  into  the  substance  cf  the  brain 
occurred  in  a  girl  11  years  old,  the  child  of  healthy  parents,  and  whose 
own  health  had  been  quite  good  until  she  was  six  years  of  age.  At  that 
time  the  extraction  of  a  molar  tooth  was  followed  by  necrosis  of  a  large 
portion  of  the  lower  jaw,  and  by  the  formation  of  abscesses  on  the  face 
and  head,  from  which  bone  escaped.  An  abscess,  attended  with  simi- 
lar exfoliation  of  bone,  formed  likewise  on  the  right  foot,  and  it  was 
three  years  before  the  child  had  recovered  completely.     Though  much 


ILLUSTRATIVE    CASES.  55 

disfigured  by  the  disease,  her  health  ever  after  continued  good  until 
April  12th,  1846.  She  was  then  suddenly  and  causelessly  attacked 
with  vomiting  and  pain  in  the  head,  for  which  no  other  treatment  was 
adopted  during  ten  days  than  the  occasional  administration  of  an 
aperient.  During  this  time,  however,  a  condition  of  stupor  gradually 
stole  over  the  child,  for  which,  on  April  21st,  a  blister  was  applied  to 
the  back  of  her  neck  with  great  relief.  On  April  23d  she  had  two 
attacks  of  convulsions,  with  an  interval  of  four  hours  between  each. 
She  struggled  much  during  their  continuance,  especially  with  the  right 
side ;  when  they  subsided,  partial  palsy  of  the  left  side  remained  :  the 
child  complained  much  of  her  head,  and  sank  from  time  to  time  into  a 
state  of  stupor,  from  which,  however,  she  could  always  be  roused. 
Very  free  purgation  on  the  24th  of  April,  and  the  application  of  another 
blister  to  the  back  of  the  neck,  were  followed  by  some  amendment.  On 
the  evening  of  the  25th  another  fit  occurred,  with  symptoms  similar  to 
those  that  had  been  observed  on  the  previous  occasions ;  but  it  was  not 
followed  by  any  increase  in  the  palsy  of  the  left  side,  nor  was  the 
degree  of  stupor  so  considerable  as  on  the  former  occasion.  Mercurials, 
which  had  been  employed  from  the  commencement  of  the  attack,  had 
now  produced  a  decided  influence  on  the  mouth,  and  the  abundant 
action  of  the  bowels  was  again  succeeded  by  much  improvement  in  the 
child's  condition.  The  pulse,  which  had  varied  from  60  to  70,  now 
continued  about  70,  and  was  natural  in  character,  and  the  child  im- 
proved daily,  though  taking  no  other  medicines  than  occasional  aperi- 
ents. The  headache  returned  occasionally,  though  each  time  it  was  less 
severe  than  the  time  before ;  but  on  the  evening  of  May  15th,  this 
amendment  was  suddenly  interrupted  by  an  attack  of  violent  pain  in 
the  abdomen,  which,  was  soon  followed  by  convulsions  and  coma,  and 
the  child  died  convulsed  in  sixteen  hours ;  on  the  36th  day  from  the 
first  attack  of  pain  in  the  head. 

On  making  an  examination  of  the  head,  permission  for  which  was 
obtained  with  difficulty,  blood  was  found  to  be  effused  into  the  sub- 
arachnoid tissue  over  a  great  part  of  the  right  hemisphere  of  the  brain. 
The  quantity  of  blood,  however,  was  no  where  very  considerable,  but 
merely  occupied  the  sulci  between  the  convolutions.  The  brain  pre- 
sented no  remarkable  appearance,  except  that  on  a  level  with,  and  just 
exterior  to  the  right  lateral  ventricle,  there  was  a  large  clot  of  blood, 
rather  larger  than  a  hen's  egg,  but  of  more  irregular  shape,  around 
which  the  brain  was  softened.  This  effusion  was  perfectly  black  through- 
out, the  coloring  particles,  of  the  blood  being  equally  diffused  through  it,, 
and  no  appearance  betokened  that  haemorrhage  had  previously  taken 
place  in  this  situation.  The  anterior  cerebral  artery  ran  for  a  conside- 
rable distance  just  outside  the  clot,  but  it  could  not  be  ascertained  that 
it  had  given  way  at  any  point. 

Cerebral  haemorrhage  is  one  of  the  few  affections  of  early  life  con- 
cerning the  treatment  of  which  but  little  can  be  said ;  for  where  the 
symptoms  of  a  disease  are  so  obscure,  it  would  be  idle  laying  down 
elaborate  rules  for  its  cure.  The  general  principles,  according  to  which 
you  would  manage  a  case  of  congestion  of  the  brain,  would  still  guide 
you  if  haemorrhage  had  taken  place.     It  cannot,  however,  be  necessary 


56  CAPILLARY    HEMORRHAGE. 

for  me  to  repeat  to-day  the  observations  on  that  point  to  which  I 
Yesterday  directed  your  attention. 

Before  concluding,  I  must  for  a  moment  refer  to  a  form  of  cerebral 
hemorrhage,  which,  though  of  no  great  importance,  yet  forms  an  excep- 
tion to  what  has  been  stated  as  to  the  rarity  of  the  accident  in  early 
life.  In  children  who  have  been  affected  with  tubercular  disease  of  the 
brain,  it  is  by  no  means  unusual  to  observe  very  small  effusions  of  blood 
in  the  midst  of  the  softened  cerebral  matter  that  surrounds  the  deposit. 
This  capillary  apoplexy,  produced  by  some  of  the  minute  vessels  of  the 
brain  giving  way,  is,  however,  seldom  extensive,  and  probably  has  but 
little  share  even  in  accelerating  the  fatal  event. 

When  next  we  meet,  we  shall  pass  from  this  subject,  which,  it  must 
be  owned,  has  more  of  a  pathological  than  of  a  practical  interest,  and 
shall  enter  on  the  study  of  the  inflammatory  affections  of  the  brain  in 
childhood. 


LECTUEE    V. 

Inflammatory  Affections  of  the  Brain — frequent  in  childhood,  but  overlooked  by 
early  writers — first  noticed  about  a  century  ago — described  under  the  name  of  acute 
hydrocephalus,  by  Dr.  Whytt. 

Acute  Hydrocephalus — progress  of  knowledge  with  reference  to  it. — The  name  re- 
stricted in  these  lectures  to  scrofulous  inflammation  of  the  brain,  which  is  much  more 
frequent  than  its  simple  inflammation  in  childhood. 

Morbid  appearances  in  acute  hydrocephalus — due  either  to  inflammation  or  to  tuber- 
cular deposit — alterations  more  apparent  in  the  membranes  at  the  base  of  the  brain 
than  in  those  of  its  convexity. — Reasons  for  considering  granulations  of  the  mem- 
branes as  tubercular. — Increase  of  fluid  in  the  ventricles  almost  invariable. — Central 
softening  of  the  brain  not  a  post-mortem  alteration — frequently  connected  with 
changes  in  the  lining  of  the  ventricles. 

Symptoms  of  the  three  stages  of  the  disease. 

Few  of  the  diseases  of  childhood  are  more  serious  than  those  inflam- 
matory affections  of  the  brain  on  the  examination  of  which  we  are  now 
about  to  enter.  They  occasion  9.8  per  cent,  of  all  deaths  under 
five  years  of  age  in  this  metropolis,  while  they  are  so  especially  the 
diseases  of  early  life,  that  814  per  cent,  of  all  cases  of  fatal  inflamma- 
tion of  the  brain  occur  in  children  under  five  years  of  age,  90.2  per 
cent,  before  the  age  of  10,  and  92*4  per  cent,  before  the  age  of  15. 1 

But  though  the  frequency  of  these  affections  in  the  young  is  a  matter 
of  such  popular  notoriety  that  most  of  you  were  familiar  with  the  fact 
long  before  you  were  engaged  in  your  present  profession,  yet  if  you 
turn  to  the  writings  of  any  of  the  old  physicians,  you  will  find  in  them 
no  mention  of  inflammation  of  the  brain  in  childhood.  At  first  this 
may  surprise  you,  but  a  few  moments'  consideration  will  explain  the 
seeming  oversight.  Convulsions,  which  form  a  prominent  symptom  in 
most  cases  of  inflammation  of  the  brain,  occur,  as  I  need  not  remind 

1  Deduced  from  5th  and  8th  Reports  of  Registrar-General  for  1842-5. 


INFLAMMATORY  AFFECTIONS    OF  THE  BRAIN.  57 

you,  in  the  course  of  many  other  affections  of  the  nervous  system.  An 
accident  so  alarming  as  a  fit  of  convulsions  is  sure  to  attract  attention, 
but  much  careful  examination  is  often  needed  to  distinguish  those  minor 
differences  between  the  symptoms  which  precede  or  accompany  it,  that 
alone  would  indicate  the  cause  to  which  it  is  due.  It  cannot,  then,  be 
surprising,  that  in  the  absence  of  this  minute  care,  many  diseases, 
though  differing  in  most  important  particulars,  should  have  long  been 
classed  together  under  the  head  of  convulsions,  and  that  inflammation 
of  the  brain  should  not  have  been  recognized  as  a  distinct  affection. 
The  importance  of  some  of  those  less  obvious  structural  changes  which 
we  know  to  be  most  significant  of  the  nature  of  previous  diseases  was 
not  then  understood,  so  that  an  alteration  in  the  consistence  of  the 
brain,  or  a  diminution  in  the  transparency  of  its  membranes,  often 
passed  unnoticed :  and  anatomical  research  was  not  exact  enough  to 
make  up  for  the  deficiencies  in  clinical  observation. 

But  just  as  the  physician's  attention  was  fixed  on  the  convulsive 
seizures  which  in  so  many  cases  affected  his  patients,  so  the  eye  of  the 
anatomist  was  often  arrested  by  the  discovery  of  a  large  quantity  of 
fluid  in  the  interior  of  the  brain.  Sometimes  this  fluid  had  been 
secreted  in  such  quantity  as  not  only  to  distend  the  ventricles  of  the 
brain,  but  to  occasion  a  manifest  enlargement  of  the  skull.  In  such 
cases  the  disease  was  essentially  chronic  in  its  course,  and  was  called, 
from  its  most  striking  characters,  dropsy  of  the  brain,  or  chronic 
hydrocephalus. 

Speculation,  however,  was  set  afloat  by  the  occasional  notice  of  cases 
in  which,  though  fluid  was  found  in  large  quantity  within  the  brain,  yet 
the  previous  disease  had  been  of  short  duration,  its  symptoms  had  been 
acute,  and  the  fever,  drowsiness,  and  cerebral  disturbance  which  attended 
it,  had  run  a  very  rapid  course  to  their  fatal  termination.  Dr.  Whytt 
was  the  first1  who,  in  the  year  1768,  clearly  pointed  out  the  connexion 
between  these  symptoms  and  the  accumulation  of  fluid  in  the  ventricles. 
His  attention,  like  that  of  previous  observers,  was  mainly  fixed  on  this 
point,  to  the  exclusion  of  other  morbid  appearances,  and  he  was  thus  led 
to  regard  the  disease  as  an  acute  dropsy  of  the  brain.  Little  can  even 
now  be  added  to  his  description  of  the  malady,  but  further  observation 
has  shown  that  the  presence  of  an  increased  quantity  of  fluid  in  the 
brain,  on  which  he  laid  so  much  stress,  is  not  of  invariable  occurrence  ; 
that  there  is  no  certain  relation  between  the  amount  of  the  fluid  and  the 
intensity  of  the  symptoms,  or  the  rapidity  of  their  course  ;  and  that  it 
is  almost  always  associated  with  other  very  important  lesions,  some  of 
which  are  the  evident  results  of  inflammation.  Many  years  were  occu- 
pied in  the  investigations  which  led  to  this  conclusion,  so  that  long  be- 
fore Whytt's  theory  had  been  ascertained  to  be  erroneous,  people  had 
grown  familiar  with  the  name  which  he  proposed  for  the  disease,  and 
in  this  country  it  is  still  called  hydrocephalus,  or  acute  hydrocephalus. 

A  most  important  step  towards  a  knowledge  of  the  true  pathology  of 
this  disease,  was  the  discovery  that  the  fluid  poured  out  into  the  ven- 
tricles is  not  a  mere  dropsical  effusion,  but  that  it  is   the  result  of 

1  In  his  Observations  on  the  Dropsy  in  the  Brain,  8vo.  Edin.  1768. 


58  SCROFULOUS   INFLAMMATION,    OR   ACUTE   HYDROCEPHALUS. 

previous  inflammatory  action.  A  difficulty,  however,  appeared  when  it 
was  ascertained  that  in  those  cases  in  which  the  signs  of  inflammation 
of  the  brain  were  most  evident  during  life,  and  its  effects  most  marked 
after  death,  both  the  symptoms  and  the  morbid  appearances  differed  in 
some  respects  from  those  usually  observed  in  Whytt's  disease.  The 
almost  invariable  existence  of  a  very  obvious  tendency  to  scrofula  in 
well-marked  instances  of  Whytt's  disease,  and  its  frequent  absence  in 
other  cases  of  inflammation  of  the  brain,  did  much  towards  solving  this 
difficulty.  It  was  next  discovered  that  in  nearly  every  instance  in 
which  Whytt's  disease  terminates  fatally,  tubercle  is  present  in 
greater  or  less  abundance  in  various  organs  of  the  body  ;  and  to  the 
acuteness  of  French  anatomists  we  owe  the  last  step  in  this  investigation, 
by  which  it  has  been  shown  that  in  the  majority  of  cases  the  membranes 
of  the  brain  themselves  are  the  seat  of  tubercular  deposite. 

We  are  thus  led  to  the  conclusion  that  inflammation  of  the  brain 
occurs  in  early  life  under  two  different  conditions.  It  now  and  then 
comes  on  in  previously  healthy  children,  but  occurs  much  ofcener  in 
connection  with  the  tuberculous  cachexia,  or  as  the  result  of  tubercular 
deposite  in  the  brain  or  its  membranes.  The  term  encephalitis  may  be 
properly  used  to  denote  the  cases  of  simple  inflammation  of  the  brain, 
while  we  may  with  advantage  restrict  the  term  acute  hydrocephalus  to 
cases  of  cerebral  inflammation  in  scrofulous  subjects.  Owing  to  the 
extreme  rarity  of  the  former  affection,  it  will,  I  think,  be  our  better 
plan  first  to  study  minutely  all  the  characters  of  acute  hydrocephalus, 
and  then  to  examine  the  points  of  difference  between  simple  and 
scrofulous  inflammation  of  the  brain. 

Wre  will  commence  this  investigation  with  an  inquiry  into  the  nature 
of  the  appearances  found  after  death  in  cases  where  acute  hydrocephalus 
has  had  a  fatal  termination.  These  may  be  divided  into  two  classes, 
according  as  they  are  the  result  of  inflammation  or  of  the  deposite  of 
tubercle  ;  and  changes  due  to  both  of  these  causes  are  often  found  in 
the  membranes  of  the  brain  as  well  as  in  its  substance. 

The  appearances  which  present  themselves  on  the  skull  being  opened 
are  seldom  very  striking,  for  the  dura  mater  is  usually  healthy,  and 
the  changes  in  the  arachnoid  are  not  in  general  of  a  kind  at  once  to 
attract  attention.  Sometimes,  indeed,  the  eye  is  struck  by  an  excessive 
vascularity  of  the  membranes,  but  this  appearance  often  depends  on 
the  overfilling  of  the  large  vessels  as  the  result  of  position.  Attentive 
examination  will  usually  enable  us  to  distinguish  between  this,  and 
that  increase  of  vascularity  which  is  produced  by  a  uniform  injection  of 
the  minuter  vessels ;  and  moderate  pressure,  while  it  causes  the 
disappearance  of  the  apparent  vascularity  in  the  former  case,  will 
produce  no  effect  on  the  true  congestion  in  the  latter. 

The  secretion  that  naturally  moistens  the  sac  of  the  arachnoid  is 
altered,  increased,  or  suppressed;  but  the  last  of  these  changes  is  the 
most  frequent,  while  the  first  is  seldom  observed  in  cases  of  hydro- 
cephalus. The  preternatural  dryness  of  the  membrane  is  usually 
connected  with  some  diminution  of  its  natural  transparency ;  it  looks 
dull  and  lustreless,  and  feels  sticky, — a  state  to  which  the  French  have 
applied  the  term  "poisseux."     The  dulness  of  the_arachnoid  is  some- 


ACUTE  HYDROCEPHALUS — MORBID  APPEARANCES.  59 

times  more  considerable,  and  it  then  presents  an  opaline  appearance, 
which  is  very  evident  at  those  parts  where  the  membrane  passes  from 
one  convolution  to  another.  This  opalescence  is  not  often  general,  but 
is  usually  most  marked  about  the  upper  part  of  the  hemispheres,  and 
in  the  neighbourhood  of  the  longitudinal  fissure. 

When  any  considerable  degree  of  vascularity  of  the  membranes  is 
evident,  this  is,  of  course,  chiefly  due  to  the  injection  of  the  minute 
vessels  of  the  pia  mater.  Such  intense  injection  of  the  pia  mater  is, 
however,  far  less  frequent  than  the  effusion  of  fluid  between  it  and  the 
arachnoid,  and  it  is  still  less  common  to  find  the  two  appearances  in 
the  same  subject.  The  effused  fluid  is  for  the  most  part  colourless  and 
transparent,  and  if  present  in  any  considerable  quantity,  the  surface 
of  the  convolutions  then  appears  as  if  covered  by  a  layer  of  transparent 
jelly,  though  on  puncturing  the  membrane  a  drop  of  clear  serum  will 
exude.  The  effusion  of  lymph  or  pus  into  the  pia  mater  covering  any 
considerable  extent  of  the  convexity  of  the  brain  is  very  seldom  met 
with,  but  deposits  of  a  yellow  puriform  lymph  are  not  infrequently  seen 
occupying  the  depressions  between  the  convolutions,  or  following  the 
course  of  the  vessels  along  the  sides,  or  at  the  upper  surface  of  the 
hemispheres. 

But  though  the  alterations  presented  by  the  membranes  at  the  con- 
vexity of  the  brain  are  often  comparatively  trivial,  the  membranes  at  the 
base  of  the  organ  almost  always  show  unequivocal  traces  of  inflam- 
matory action.  The  predominance  of  the  affection  of  the  membranes 
at  the  base  of  the  brain  has  indeed  been  regarded  by  some  writers  as 
pathognomonic  of  scrofulous  inflammation  of  the  organ  j1  and  though 
this  rule  is  not  without  exception  still  it  holds  good  in  the  vast  majority 
of  cases.  In  30  out  of  35  fatal  cases  of  acute  hydrocephalus,  in  which 
I  carefully  recorded  the  condition  of  the  membranes,  those  at  the  base 
of  the  brain  were  found  to  be  the  seat  of  disease  more  or  less  extensive, 
and  always  more  considerable  than  that  which  existed  at  the  vertex. 
In  one  of  the  cases  in  which  the  membranes  at  the  base  wTere  healthy, 
there  was  a  good  deal  of  serous  effusion  beneath  the  arachnoid  at  the 
convexity ;  and  in  another  instance  there  was  some  fluid  in  the  sac  of 
the  arachnoid,  and  the  pia  mater  covering  the  upper  surface  of  the 
brain  was  greatly  injected;  but  in  the  two  remaining  cases  the  mem- 
branes at  the  upper,  as  well  as  those  at  the  lower  part  of  the  brain, 
were  perfectly  healthy. 

The  least  considerable  of  the  morbid  changes  in  the  membranes  at 
the  base  of  the  brain  consists  in  a  milky  or  opaline  condition  of  the 
arachnoid  and  pia  mater,  but  chiefly  of  the  former,  sometimes  extending 
over  the  whole  lower  surface  of  the  cerebrum,  but  seldom  being  equally 
apparent  in  that  part  of  the  membrane  which  invests  the  cerebellum. 
But,  besides  this  opacity,  we  usually  observe  much  more  distinct  evi- 
dence of  inflammatory  action  in  the  effusion  of  yellow  lymph  beneath 
the  arachnoid.     This  is  generally  found  about  the  olfactory  nerves, 

1  On  which  subject  the  valuable  essay  of  M.  Rilliet,  De  l'lnflammation  franche  des 
Meninges  chez  les  Enfants,  in  the  Archives  de  Medecine,  for  Dec.  Jan.  and  Feb.  1846-7, 
may  be  consulted  with  advantage. 


60  GRANULATIONS  OF  THE  MEMBRANES. 

which  are  often  completely  imbedded  in  it,  while  a  similar  effusion 
extending  across  the  longitudinal  fissure  unites  the  two  hemispheres  of 
the  brain  together.  A  deposit  of  the  same  kind  likewise  reaches  up  the 
fissure  of  Sylvius  in  many  cases,  and  connects  the  anterior  and  middle 
lobes  of  the  brain  with  each  other ;  or  if  poured  out  in  less  abundance, 
it  may  be  seen  running  up  in  narrow  yellow  lines  by  the  side  of  the 
vessels  as  they  pass  from  the  base  of  the  brain  towards  its  convexity. 
It  is  in  the  neighbourhood  of  the  pons  Varolii,  however,  and  about  the 
optic  nerves,  that  the  most  remarkable  alterations  are  met  with.  The 
opacity  of  the  arachnoid  is  here  particularly  evident,  while  the  subjacent 
pia  mater  is  opaque,  much  thickened,  and  often  infiltrated  with  a  pecu- 
liar semi-transparent  gelatinous  matter,  sometimes  of  a  dirty  yellowish- 
green  colour.  This  matter  is  sometimes  so  abundant  as  perfectly  to 
conceal  the  third  and  fourth  nerves,  and  at  the  same  time  to  invest  the 
optic  nerves  with  a  coating  two  or  three  lines  in  thickness ;  though,  on 
being  dissecfed  off,  the  substance  of  the  nerves  beneath  appears  quite 
healthy.  When  this  morbid  condition  exists  in  any  very  considerable 
degree  it  extends  beyond  the  pons,  and  involves  the  membranes  covering 
the  medulla  oblongata,  especially  at  its  anterior  surface. 

It  is  only  within  the  past  sixteen  or  seventeen  years  that  attention 
has  been  drawn  to  the  importance  of  another  element  besides  mere 
inflammation,  in  the  production  of  acute  hydrocephalus.  The  peculiar 
granular  appearances  which  various  parts  of  the  membranes  of  the  brain 
often  present  in  this  disease,  though  noticed  many  years  before,  began 
then  to  engage  the  special  attention  of  several  French  physicians.1 
The  conclusion  to  which  we  are  led  by  their  careful  investigation  of  the 
subject,  is,  that  this  appearance  is  not  due  to  inflammation,  as  was  once 
supposed,  but  that  it  is  occasioned  by  the  presence  of  tubercular  deposits. 
These  deposits  often  assume  the  form  of  minute,  flattened,  spherical 
bodies  of  the  size  of  a  small  pin's  head,  or  smaller,  and  either  of  a  yel- 
lowish colour,  and  rather  friable  under  pressure,  or  greyish,  semi-trans- 
parent, and  resistant,  almost  exactly  resembling  the  grey  granulations 
which  are  sometimes  seen  in  the  lungs  or  pleurge  of  phthisical  subjects, 
They  are  likewise  sometimes  met  with  in  what  would  seem  to  be  an 
earlier  stage,  when  they'appear  like  small  opaque  spots  of  a  dead  white 
colour,  much  smaller  than  a  pin's  head,  and  communicating  no  percep- 
tible roughness  to  the  membrane.  This  appearance  is  often  observed 
in  the  arachnoid  covering  the  cerebellum,  and  those  parts  of  the  base 
of  the  brain  where  the  arachnoid  is  stretched  across  from  one  part  of 
the  organ  to  another.  The  flattened  yellowish  bodies  are  most  fre- 
quently seen  at  the  convexity  of  the  brain,  and  on  either  side  of  the 
hemispheres.  They  generally  follow  the  course  of  the  vessels  that 
ramify  in  the  pia  mater,  and  accordingly  occupy  the  sulci  between  the 
convolutions  much  oftener  than  their  summit.  The  firm  grey  bodies  are 
mostly  seen  about  the  pons,  or  imbedded  in  the  pia  mater  in  the 
neighbourhood  of  the  optic  nerves,  or  projecting  from  the  surface  of  the 


1  M.  Papavoine  appears  to  have  been  the  first  who,  in  the  Journal  Hebdomadaire  for 
1830,  vol.  vi.  p.  113,  clearly  established  the  tubercular  nature  of  these  granulations  of 
the  membranes  of  the  brain. 


TUBERCULAR  NATURE   OF   THE   GRANULATIONS.  61 

membranes  that  cover  the  medulla  oblongata.  They  are  also  often 
deposited  in  the  arachnoid  lining  the  occipital  bone,  and  are  then  some- 
times collected  in  considerable  numbers  around  the  foramen  magnum. 
These  bodies,  sometimes  of  a  grey,  at  other  times  of  a  yellow  colour, 
are  likewise  met  with,  though  less  frequently,  in  the  substance  of  the 
velum  interpositum,  or  imbedded  in  the  choroid  plexuses,  and  in  both 
of  these  situations  they  are  sometimes  very  abundant. 

These  bodies,  however,  do  not  always  retain  the  appearance  of  distinct 
granules,  but  sometimes  on  separating  two  folds  of  the  arachnoid  which 
had  seemed  to  be  glued  together  by  an  effusion  of  yellow  lymph  or  con- 
crete pus,  we  find  that  the  matter  which  forms  these  adhesions  is  not 
homogeneous,  but  that  it  consists  of  an  aggregation  of  minute  granular 
bodies  connected  together  by  the  lymph  or  pus  in  which  they  are  im- 
bedded. This  appearance  is  often  met  with  at  the  convexity  of  the 
brain,  and  close  to  the  longitudinal  fissure,  and  rather  more  towards 
its  posterior  than  its  anterior  part ;  a  strip  of  this  yellow  matter,  half 
an  inch  long  by  two  or  three  lines  broad,  connecting  together  the  two 
hemispheres  of  the  brain  or  the  two  surfaces  of  the  arachnoid.  Some- 
times two  or  three  deposits  of  this  kind  are  observed  at  the  convex 
surface  of  the  brain,  but  they  are  generally  more  extensive  at  the  base 
of  the  organ,  where  they  occupy  the  longitudinal  fissure  and  the  fissure 
of  Sylvius,  and  frequently  connect  opposite  surfaces  of  the  brain  so 
closely  together  as  to  render  their  separation  impossible  without  injury 
to  its  substance.  But  you  may  ask  me  for  the  proof  of  these  granular 
bodies  being,  as  I  have  represented  them  to  be,  real  tubercular  deposits. 
It  would  occupy  nearly  the  whole  of  this  lecture  to  detail  all  the  argu- 
ments that  have  been  adduced  on  both  sides  of  the  question,  for  it  is  a 
question  which  has  been  much  disputed ;  some  persons  being  disposed 
to  regard  them  merely  as  products  of  inflammation. 

The  reasons  which  appear  to  me  to  be  conclusive  in  favour  of  the 
tubercular  nature  of  these  bodies,  are — 

1st.  That  they  are  always  associated  with  tubercle  elsewhere. 

2d.  That  their  abundance  is  not  in  proportion  to  the  amount  of 
inflammatory  mischief. 

3d.  That  they  are  sometimes  met  with  in  cases  where  no  head  symp- 
toms were  observed  during  life,  and  unconnected  with  any  sign  of 
inflammation  discovered  after  death ;  and 

4th.  That  their  chemical  composition  and  their  microscopic  structure 
are  identical  with  those  of  tubercle  in  other  organs  of  the  body.1 

Notwithstanding  the  important  nature  of  the  changes  presented  by 
the  membranes  of  the  brain  in  cases  of  acute  hydrocephalus,  it  was 
long  before  they  attracted  as  much  attention  as  the  alterations  in  the 
substance  of  the  brain  itself,  and  especially  as  that  distension  of  its 
cavities  with  fluid  from  which  the  malady  has  derived  its  name.  The 
surface  of  the  brain,  indeed,  generally  presents  but  few  traces  of  disease, 
though  sometimes  the  convolutions  are  greatly  flattened,  and  the  sulci 

1  With  reference  to  these  two  points,  see  Becquerel,  Recherches  Cliniques  sur  la 
Meningite  des  Enfans,  8vo.  Paris,  1838,  p.  20 ;  and  Lebert,  Physiologie  Pathologique, 
&c.  8vo.  Paris,  1845,  vol.  i.  p.  440-449. 


62  SOFTENING   OF   THE   CEREBRAL   SUBSTANCE. 

between  them  almost  obliterated  by  the  pressure  of  the  fluid  from 
within.  The  cerebral  substance  is  often  healthy  as  low  down  as  the 
centre  of  Vieussens,  or  presents  no  change  more  important  than  the 
presence  of  an  unusual  number  of  bloody  points,  the  divided  cerebral 
vessels.  But,  though  unaltered  to  the  eye,  a  diminution  of  consistence 
is  often  perceptible  as  the  ventricles  are  approached.  Sometimes  the 
whole  brain  seems  softer  than  natural,  while  at  other  times,  though  not 
actually  softened,  it  is  infiltrated  with  fluid,  as  though  it  had  soaked  up 
the  serum  from  the  ventricles. 

The  presence  of  a  larger  quantity  of  fluid  than  natural  in  the  lateral 
ventricles  is  of  almost  constant  occurrence.  In  34  out  of  36  cases  in 
which  death  had  taken  place  under  the  symptoms  of  acute  hydroce- 
phalus, I  found  an  appreciable  quantity  of  fluid  in  the  ventricles ;  and 
in  32  of  these  cases  the  quantity  was  considerable,  amounting  to  several 
ounces.  The  fluid  is  in  general  a  perfectly  transparent  serum,  resem- 
bling passive  effusions  poured  out  from  other  serous  membranes  ;  and 
such  it  doubtless  is  in  many  cases  in  which  it  is  found  distending  the 
lateral  ventricles.  But,  in  a  large  proportion  of  instances  of  hydroce- 
phalus, the  increased  secretion  in  the  ventricles  is  associated  with  a 
very  notable  change  in  the  surrounding  cerebral  substance.  This 
change  consists  in  a  loss  of  the  natural  firmness  of  the  central  parts  of 
the  brain,  which  varies  in  degree  from  a  slight  diminution  of  consistence 
to  a  state  of  perfect  diffluence,  in  which  their  texture  becomes  perfectly 
disorganized,  and  they  form  a  pulpy  mass  that  is  easily  washed  away 
by  a  stream , of  water ;  or  the  softening  may  be  even  more  considerable, 
and  the  cerebral  matter  may  become  semifluid,  and  may  closely  resem- 
ble thick  cream.  The  parts  thus  affected  are  perfectly  pale  and  blood- 
less, and  the  cerebral  substance  in  the  neighbourhood  is  usually  rather 
ansemic.  The  fornix,  septum  lucidum,  corpus  callosum,  and  posterior 
horn  of  the  lateral  ventricles,  are  the  parts  most  frequently  affected  ;  the 
optic  thalami,  corpora  striata,  and  lower  parts  of  the  middle  and  pos- 
terior lobes  of  the  brain,  rank  next  in  this  respect,  while  the  anterior 
lobes  are  but  seldom  softened.  In  a  few  instances  the  cerebellum  is 
involved  in  the  softening,  and  now  and  then  the  whole  brain  is  found 
to.  have  lost  much  of  its  natural  firmness, — a  change,  however,  which  is 
usually  much  more  marked  on  one  side  than  the  other.  Closely  allied  to 
this  softening  is  the  state  to  which  I  have  already  referred,  wherein  the 
wdiole  brain  appears  perfectly  infiltrated  with  serum,  as  though  it  had 
been  long  soaked  in  it,  and  had  imbibed  it  like  a  sponge. 

A  mechanical  explanation  has  been  frequently  suggested  to  account 
both  for  this  appearance  and  the  central  softening  of  the  brain,  which 
you  will  observe  is  most  marked  in  those  very  parts  to  which  the  fluid 
in  the  ventricles  would  naturally  gravitate  after  death.  Many  facts, 
however,  are  opposed  to  this  view  of  the  cause  of  softening  of  the  brain. 
If  it  were  a  change  induced  by  the  imbibition  of  fluid  after  death,  we 
should  expect  to  find  it  as  constant  as  is  hypostatic  congestion  of  the 
lungs;  but  instead  of  this  being  the  case,  fluid  is  found  in  many 
instances  in  the  ventricles  without  the  consistence  of  the  brain  being  in 
the  least  diminished.  In  a  recent  work  on  Acute  Hydrocephalus,  which 
embodies  the  results  of  a  very  large  number  of  dissections,  it  is  stated 


SOFTENING   NOT  DUE   TO   IMBIBITION   OF  FLUID,  63 

that  central  softening  of  the  brain  existed  only  in  47  out  of  71  instances, 
in  which  the  ventricles  contained  a  quantity  of  serum  varying  from  3 
to  11  ounces.1  In  my  records  of  the  examination  of  the  brain  in  hydro- 
cephalus, I  have  preserved  an  accurate  account  of  the  condition  of  the 
cerebral  substance  in  34  cases,  and  find  that  in  12  instances  there  was 
not  the  least  central  softening,  although  the  ventricles  contained  fluid 
in  every  case  but  one,  and  the  quantity  amounted  on  seven  occasions 
to  several  ounces.  M.  Louis,  too,  mentions  in  his  work  on  Phthisis,3 
that  in  75  out  of  101  tubercular  subjects,  each  ventricle  contained  a 
quantity  of  fluid  varying  from  half  an  ounce  to  two  or  three  ounces, 
but  yet  in  only  6  of  these  101  cases  were  the  central  parts  of  the  brain 
at  all  softened.  And,  not  to  dwell  on  any  other  arguments  which  might 
be  adduced,  it  may  be  added  that  M.  Rokitansky  has  subjected  the 
supposed  hygroscopic  property  of  the  brain  to  the  test  of  experiment, 
and  found  that  no  change  whatever  was  produced  in  slices  of  cerebral 
matter  by  soaking  them  for  hours  in  serum. 

But  if  we  reject  the  theory  of  this  change  in  the  brain  being  a  mere 
post-mortem  occurrence,  the  question  still  remains,  to  what  is  it  due  ? 
M.  Rokitansky  regards  it  as  a  condition  of  acute  oedema  of  the  brain, 
often,  though  not  invariably,  associated  with  inflammation,  since  its 
products,  pus  and  exudation  corpuscles,  are  usually  found  in  the  broken- 
down  or  infiltrated  nervous  matter. 

One  very  strong  proof  of  the  close  connection  that  subsists  between 
softening  of  the  brain  and  an  inflammatory  process  going  on  in  the 
organ,  is  furnished  by  the  changes  which  in  many  of  these  cases  may 
be  observed  in  the  lining  membrane  of  the  ventricles.     In  20  cases  of 
acute  hydrocephalus,  in  which  central  softening  of  the  brain  co-existed 
with  the  presence  of  fluid  in  the  ventricles,  accurate  notes  were  taken 
of  the  condition  of  their  lining,  and  in  three  instances  only  was  it  found 
to  be  healthy.     In  one  of  these  three  cases  the  central  softening  was 
very  inconsiderable,  and  in  the  other  two  cases  the  softening  of  the 
central  parts  was  associated  with  very  marked  softening  of  other  parts 
of  the  brain,  which  were  altered  in  colour  as  well  as  in  consistence. 
The  lining  of  the  ventricles  in  the  remaining  17  cases  was  notably 
altered,  although  the  degree  of  its  change  was  very  variable.     The  first 
alteration  that  takes  place  in  it  is  the  loss  of  its  transparency,  which  is 
often,  though  not  always,  associated  with  a  turgid  state  of  its  vessels. 
It  next  acquires  an  unnatural  toughness,  so  that  it  can  be  raised  by  the 
point  of  the  scalpel :  and  sometimes  it  is  not  merely  opaque  and  tough, 
but  greatly  thickened,  forming  a  dense  firm  membrane ;   and  once  or 
twice  I  have  noticed  its  inner  surface  present  a  slightly  granular  ap- 
pearance.    These  changes  in  the  membrane  do  not  bear  any  certain 
relation  to  the  quantity  of  fluid  or  to  the  degree  of  central  softening, 
though  it  is  rare  to  find  an  extreme  degree  of  change  in  the  lining  of 
the  ventricles  without  a  considerable  quantity  of  fluid  in  their  cavity 
and  great  softening  of  the  brain  around  them.3 

1  Beobachtungen  und  Bemerkungen  iiber  den  rasch  verlaufenden  Wasserkopf.     Von 
K.  Herrich.     8vo.     Regensburg,  1847,  p.  161,  g  126. 

2  Recherches  surla  Phthisic     2de  eU  8vo.     Paris,  1843,  p.  160,  g  161. 

3  The  subjoined  note  contains  an  analysis  of  my  dissections  of  36  cases  of  acute 


64  BUT   THE   RESULT   OF  INFLAMMATION. 

It  happens  sometimes  that  we  find  large  patches  of  tubercular  matter 
deposited  beneath  the  membranes  on  the  convex  surface  of  the  brain, 
and  extending  to  the  depth  of  about  a  line  into  its  tissue,  in  children 
who  have  died  of  acute  hydrocephalus.  Now  and  then,  also,  masses  of 
tubercle,  of  a  spheroidal  shape,  and  of  various  sizes,  are  found  imbedded 
in  the  cerebral  substance.  This  latter  appearance,  however,  is  not 
frequent ;  it  existed  only  in  three  out  of  the  thirty-six  cases  on  which  I 
have  founded  my  remarks  on  the  morbid  anatomy  of  acute  hydroce- 
phalus ;  and  even  in  these  cases  peculiar  symptoms  existed  which  during 
the  lifetime  of  the  patient  led  to  the  suspicion  of  the  disease  being 
something  else  than  an  ordinary  attack  of  water  on  the  brain. 

The  complications  of  hydrocephalus  consist  almost  entirely  in  the 
deposit  of  tubercle  in  many  organs  of  the  body,  and  in  various  results 
to  which  that  tubercular  deposit  may  have  given  rise.     The  lungs  and 

hydrocephalus,  as  far  as  respects  the  presence  of  fluid  in  the  ventricles,  the  state  of 
their  lining  membrane,  and  the  condition  of  the  cerebral  substance  ;  particulars  the 
mutual  relation  of  which  to  each  other  have  not  yet  been  fully  investigated. 

In  12  of  these  36  cases  there  is  no  express  mention  of  the  condition  of  the  lining  of 
the  ventricles. 

In  2  the  state  of  the  cerebral  substance  is  only  imperfectly  described. 

In  84  the  condition  of  the  cerebral  substance  was  carefully  noted,  and  in  12  of  these 
cases  the  brain  was  not  softened  at  its  centre. 

In  1  of  these  12  cases  the  ventricles  contained  no  fluid. 


very  little, 
not  above  1  oz. 
l-£  oz. 

3  oz. 

4  oz. 
6  oz. 
a  considerable  quantity. 


In  4  of  these  12  cases  the  state  of  the  lining  of  the  ventricles^  is  likewise  expressly 
described. 

In  1,  in  which  there  was  no  fluid  in  the  ventricles,  and  in  1  in  which  there  was  very 
little  fluid,  their  lining  was  not  altered. 

In  1,  in  which  there  was  no  fluid,  the  choroid  plexuses  were  beset  with  tubercular 
granulations. 

In  1,  in  which  there  were  4  oz.  of  fluid,  their  lining  was  slightly  opaque. 

In  10  of  these  12  cases  the  consistence  of  the  cerebral  substance  was  everywhere 
natural. 

In  1  the  brain  was  generally  firmer  than  usual. 

In  1  the  anterior  parts  of  both  posterior  cerebral  lobes,  and  the  whole  of  the  cere- 
bellum, were  softened, — changes  which  were  most  evident  on  the  left  side. 

In  22  cases  the  central  parts  of  the  brain  were  softened. 

In  8  of  these  22  cases  the  softening  was  but  slight  at  the  centre. 

In  1  of  these  8  cases  the  substance  of  the  brain  elsewhere  was  healthy :  six  ounces 
of  fluid  in  the  ventricles,  their  lining  healthy. 

In  2  of  these  8  cases  the  substance  of  the  brain  elsewhere  was  healthy :  four  ounces 
of  fluid  in  the  ventricles,  their  lining  granular ;  and  lymph  was  in  one  of  the  cases 
adherent  to  the  choroid  plexuses. 

In  1  of  these  8  cases  the  substance  of  the  brain  elsewhere  was  healthy ;  much  fluid  in 
the  ventricles,  their  vessels  large,  choroid  plexuses  turgid. 

In  1  of  these  8  cases  the  substance  of  the  brain  elsewhere  was  healthy ;  much  fluid 
in  the  ventricles,  their  lining  opaque,  and  vessels  turgid. 

In  1  there  was  much  yellow  softening  of  the  anterior  and  lower  half  of  the  middle 
lobes,  greater  in  degree  and  extent  on  the  left  side  ;  not  above  half  an  ounce  of  fluid  in 
the  ventricles. 

In  1,  the  substance  of  the  brain  generally  was  very  vascular,  the  lining  of  the  ven- 
tricles tough ;  there  was  some  softening  of  each  posterior  horn ;  considerable  of  the 
left ;  which  moreover  contained  a  good  deal  of  fluid,  great  effusion  of  lymph,  and  hya- 
line matter  at  base  of  the  brain. 


ACUTE   HYDROCEPHALUS —  65 

the  bronchial  glands  are  the  parts  most  frequently  and  most  seriously 
invaded  by  the  tubercular  deposit;  the  spleen,  liver,  mesenteric  glands, 
and  intestines,  rank  next  in  frequency  as  the  seat  of  tubercle.  The 
complication  of  hydrocephalus  with  tuberculous  ulceration  of  the  intes- 
tines is  one  which,  though  not  very  frequent,  must  not  be  lost  sight  of, 
since  its  existence  may  give  rise  to  diarrhoea,  and  thus  lead  to  an  error 
of  diagnosis  on  your  part,  if  you  look  for  constipation  of  the  bowels  as 
an  invariable  symptom  of  water  on  the  brain. 

But  let  us  now  pass  to  the  examination  of  the  symptoms  of  acute  hy- 
drocephalus. We  cannot,  however,  do  more  to-day  than  familiarize 
ourselves  with  the  main  features  of  the  disease,  and  must  leave  all 
attempts  at  filling  up  the  outline  to  our  next  meeting. 

The  first  or  premonitory  stage  of  the  affection  is  attended  with  many 
indications  of  cerebral  congestion,  coupled  with  general  febrile  dis- 
turbance, and  presenting  exacerbations  and  remissions  at  irregular 
periods.  The  child  becomes  gloomy,  pettish  and  slow  in  its  movements, 
and  is  little  pleased  by  its  usual  amusements.  Or,  at  other  times,  its 
spirits  are  very  variable  ;  it  will  sometimes  cease  suddenly  in  the  midst 

And,  lastly,  in  1,  the  anterior  horn  of  the  left,  and  the  posterior  of  the  right  ventricle, 
•were  softened  •  the  ventricles  contained  four  ounces  of  clear  fluid  ;  their  lining  was 
granular,  much  thickened,  and  its  vascularity  increased. 

In  14  instances  the  central  softening  was  considerable. 

In  4  of  these  14  cases  the  cerebral  substance  elsewhere  was  softened  also. 

In  1  of  these  4  cases,  both  posterior  lobes  were  softened,  especially  the  right,  and 
the  brain  there  had  an  uniform  yellowish  white  colour. 

In  1  of  these  4  cases,  the  brain  was  very  vascular  down  to  the  centre  of  Vieussens  ; 
the  lower  and  posterior  third  of  left  posterior  lobe  was  of  a  yellowish  white  colour,  and 
quite  fluid.     Six  ounces  of  fluid  in  the  ventricles.     Cerebellum  soft. 

In  1  of  these  cases,  there  was  great  congestion  of  the  brain,  and  general  softening, 
increased  towards  the  centre.     Much  turbid  reddish  fluid  in  the  ventricles. 

In  the  last  of  these  4  cages  the  cerebral  substance  was  natural  down  to  the  centre  of 
Vieussens,  but  below  it  was  greatly  softened,  especially  on  the  left  side,  where  the  grey 
and  white  matters  were  scarcely  distinguishable  from  each  other. 

In  5  other  cases  the  lining  of  the  ventricles  was  altered,  but  there  was  no  softening 
except  at  the  centre. 

In  2  it  had  lost  its  polish,  and  was  slightly  thickened.  Six  ounces  of  fluid  in  the 
ventricles  in  one  instance,  and  only  two  in  the  other. 

In  1  it  was  thickened  and  dull.     Much  fluid  in  the  ventricles. 

In  1  it  was  opaque  and  thickened.     Much  fluid  in  the  ventricles. 

In  1  there  were  only  three  ounces  of  fluid  in  the  ventricles,  but  their  lining  partook 
of  the  general  softening  ;  the  central  parts  of  the  brain  being  almost  diffluent. 

In  5  instances  the  lining  of  the  ventricles  was  altered,  and  the  cerebral  substance 
elsewhere  softened,  viz. : — 

In  1  the  whole  brain  was  softened ;  the  thalami  optici  were  of  a  gelatinous  consis- 
tence for  a  quarter  of  an  inch  deep :  there  was  much  fluid  in  the  ventricles,  and  their 
lining  was  opaque. 

In  1  there  was  increased  vascularity  and  general  softening  of  the  cerebrum  and  cere- 
bellum ;  much  fluid  in  the  ventricles,  and  their  lining  very  thick  and  firm. 

In  1  softening  began  about  half  an  inch  below  the  surface  of  the  brain,  and  increased 
towards  the  centre ;  much  fluid  in  the  ventricles,  and  their  lining  remarkably  thick. 

In  1  there  was  great  softening  of  both  posterior  lobes,  especially  of  the  right ;  two 
ounces  of  fluid  in  the  ventricles,  and  their  lining  but  slightly  opaque. 

In  1  there  was  great  vascularity,  especially  of  the  grey  matter  of  the  convolutions ; 
extreme  softening  of  the  anterior  and  middle  lobes,  proceeding  from  the  longitudinal 
fissure  outwards,  most  marked  on  the  right  side ;  but  the  posterior  lobe  was  not  at  all 
affected.  There  was  capillary  apoplexy  of  the  left  corpus  striatum.  The  ventricles 
contained  four  ounces  of  turbid  rose-coloured  serum ;  their  lining  membrane  was 
very  vascular,  thick,  and  firm  in  some  parts, — thick,  soft,  and  actually  desintegrated 
in  others. 

5 


66  SYMPTOMS   OF   ITS   THREE   STAGES. 

of  its  play,  and  run  to  hide  its  head  in  its  mother's  lap,  putting  its  hand 
to  its  head,  and  complaining  of  headache,  or  saying  merely  that  it  is  tired 
and  sleepy,  and  wants  to  go  to  bed.  Sometimes,  too,  it  turns  giddy,  as 
you  will  know,  not  so  much  from  its  complaint  of  dizziness,  as  from  its 
suddenly  standing  still,  gazing  around  for  a  moment  as  if  lost,  and  then, 
eithe^  beginning  to  cry  at  the  strange  sensation,  or  seeming  to  awake 
from  a  reverie,  and  at  once  returning  to  its  play.  The  infant  in  its 
nurse's  arms  betrays  the  same  sensation  by  a  sudden  look  of  alarm,  a 
momentary  cry,  and  a  hasty  clinging  to  its  nurse.  If  the  child  can  walk, 
it  may  be  observed  to  drag  one  leg,  halting  in  its  gait,  though  but 
slightly,  and  seldom  as  much  at  one  time  as  at  another,  so  that  both 
the  parents  and  the  medical  attendant  may  be  disposed  to  attribute  it 
to  an  ungainly  habit  which  the  child  has  contracted.  The  appetite  is 
usually  bad,  though  sometimes  very  variable ;  and  the  child  when 
apparently  busy  at  play  may  all  at  once  throw  down  its  toys  and  beg 
for  food ;  then  refuse  what  is  offered,  or,  taking  a  hasty  bite,  may  seem 
to  nauseate  the  half-tasted  morsel,  may  open  its  mouth,  stretch  out  its 
tongue,  and  heave  as  if  about  to  vomit.  The  thirst  is  seldom  con- 
siderable, and  sometimes  there  is  an  actual  aversion  to  drink  as  well  as 
to  food,  apparently  from  its  exciting  or  increasing  the  sickness.  The 
stomach,  however,  seldom  rejects  everything ;  but  the  same  food  as 
occasions  sickness  at  one  time  is  retained  at  another.  Sometimes  the 
child  vomits  only  after  taking  food ;  at  other  times,  even  when  the 
stomach  is  empty,  it  brings  up  some  greenish  phlegm  without  much 
effort  and  with  no  relief.  These  attacks  of  vomiting  seldom  occur 
oftener  than  two  or  three  times  a  day ;  but  they  may  return  for  several 
days  together,  the  child's  head  probably  growing  heavier,  and  its 
headache  more  severe.  The  bowels  during  this  time  are  disordered, 
generally  constipated  from  the  very  first,  though  their.condition  in  this 
respect  sometimes  varies  at  the  commencement  of  the  disease.  The 
evacuations  are  usually  scanty,  sometimes  pale,  often  of  different 
colours,  almost  always  deficient  in  bile,  frequently  mud  coloured,  and 
very  offensive.  The  abdomen  is  seldom  full ;  the  child  sometimes  com- 
plains of  pain  in  it,  and  it  is  tender  on  pressure.  The  tongue  is  not 
dry,  generally  rather  red  at  the  tip  and  edges,  coated  with  white  fur 
in  the  centre,  which  becomes  yellowish  towards  the  root.  Occasionally 
I  have  seen  it  very  moist,  and  uniformly  coated  with  a  thin  white  fur. 
The  skin  is  harsh,  but  there  is  no  great  heat  of  surface ;  the  nares  are 
dry,  the  eyes  lustreless,  the  pulse  accelerated,  but  seldom  exceeding 
120  in  children  of  four  years  old  and  upwards ;  not  full  nor  strong,  but 
often  unequal  in  the  force  and  duration  of  its  beats.  The  child  is 
drowsy,  and  will  sometimes  want  to  be  put  to  bed  two  or  three  times  in 
the  day ;  but  it  is  restless,  sleeps  ill,  grinds  its  teeth  in  sleep,  lies  with 
its  eyes  partially  open,  awakes  with  the  slightest  noise,  or  even  starts 
up  in  alarm  without  any  apparent  cause.  At  night,  too,  the  existence 
of  intolerance  of  light  is  often  first  noticed  in  consequence  of  the  child's 
complaints  about  the  presence  of  the  candle  in  the  room. 

I  need  scarcely  say  that  you  must  not  expect  to  find  all  these  symp- 
toms in  every  case,  neither,  indeed,  when  present  are  they  persistent, 
but  the  child's  condition  varies  greatly  in  the  course  of  a  few  minutes  ; 


ACUTE   HYDROCEPHALUS —  67 

cheerfulness  alternating  with  depression,  and  sound  sleep  being  now  and 
then  enjoyed  in  the  midst  of  the  unrefreshing  dozes  of  the  night.  It 
will  not  be  by  a  hurried  visit  of  a  few  minutes  that  you  will  learn  these 
things ;  you  must  not  grudge  your  time,  if  you  hope  ever  to  attain  to 
excellence  in  the  management  of  children's  diseases. 

This  precursory  stage  is  of  very  variable  duration,  but  on  the  average 
does  not  exceed  four  or  five  days.  If  the  disease  be  not  recognised,  or 
if  the  treatment  adopted  be  unsuccessful,  it  will  pass  into  the  second 
stage,  in  which  the  nature  of  the  affection  is  very  apparent,  though 
unhappily  the  prospect  of  its  cure  is  almost  lost.  The  child  no  longer 
has  intervals  of  cheerfulness,  nor  attempts  to  sit  up,  but  wishes  to  be 
left  quiet  in  bed,  and  the  face  assumes  a  permanent  expression  of  anxiety 
and  suffering.  The  eyes  are  often  kept  closed,  and  the  eyebrows  are 
knit,  the  child  endeavouring  to  shut  out  the  light  from  its  morbidly 
sensitive  retina.  The  skin  continues  dry,  the  face  is  sometimes  flushed, 
and  the  head  often  hot ;  and  though  these  two  symptoms  vary  much  in 
their  duration,  coming  and  going  without  any  evident  cause,  yet  there 
is  a  permanently  increased  pulsation  of  the  carotids,  and  if  the  skull  be 
not  ossified  the  brain  may  be  felt  and  seen  forcibly  beating  through  the 
anterior  fontanelle.  The  child  is  now  very  averse  to  being  disturbed, 
and  often  lies  in  a  drowsy  condition,  unless  spoken  to,  when,  if  old 
enough  to  answer,  it  usually  complains  of  its  head,  or  of  weariness  or 
sleepiness.  Its  replies  are  generally  rational,  but  very  short ;  and  if  it 
need  anything,  it  asks  in  as  few  words  as  possible,  in  a  quick,  pettish 
manner,  and  shows  much  irritability  if  not  at  once  attended  to.  At 
other  times  it  lies  with  its  face  turned  from  the  light,  either  quite  quiet, 
or  moaning  in  a  low  tone  of  voice,  and  now  and  then  uttering  a  short, 
sharp,  lamentable  cry,  which  M.  Coindet,  of  Geneva,  regarded  as 
characteristic  of  the  disease,  and  hence  termed  it  crihydreneephalique  ; 
but  making  no  other  complaint  than  the  low  moan  and  the  occasional 
plaintive  cry.  To  this,  however,  there  are  exceptions,  and  children 
sometimes  scream  with  the  intensity  of  the  pain,  or  cry  out,  "  My 
head  !  my  head !"  most  piteously.  As  night  comes  on  there  is  almost 
always  a  distinct  exacerbation  of  the  symptoms,  and  the  quiet  of  the 
day  is  frequently  succeeded  by  a  noisy  and  excited  state,  in  which 
vociferous  cries  about  the  head  alternate  with  delirium.  This,  however, 
is  not  by  any  means  a  constant  occurrence ;  an  increase  of  restlessness 
being  often  the  only  difference  from  the  state  of  stupor  in  which  the 
child  lay  during  the  day.  At  the  commencement  of  this  stage  the 
pulse  is  quickened,  sometimes  very  much  so,  and  is  in  many  cases 
unequal  in  the  force  and  quickness  of  the  beats.  Irregularity  of  its 
rhythm,  or  distinct  intermission  in  its  beat,  is  the  next  change,  and  is 
usually  perceived  at  the  same  time  with  a  great  diminution  in  its  fre- 
quency, which  often  falls  in  a  few  hours  from  120  to  90  or  80.  At  the  same 
time  that  these  changes  take  place  in  the  general  characters  of  the 
pulse,  its  power  becomes  manifestly  diminished,  while  the  slightest 
exertion,  such  as  attends  any  alteration  in  the  child's  position  in  the 
bed,  will  often  suffice  to  increase  its  frequency  twenty  beats  or  more  in 
the  minute.  The  child  sometimes  keeps  its  eyes  so  firmly  closed  that 
we  can  scarcely  see  the  state  of  its  pupils.     Usually  they  are  not  much 


DO  SYMPTOMS   OP  ITS   THREE   STAGES. 

affected,  but  sometimes  one  is  more  dilated  and  acts  more  sluggishly 
than  the  other,  or  in  other  cases,  strabismus  exists,  though  perhaps  in 
a  very  slight  degree ;  or  confined  to  one  eye.  It  is  seldom  that 
vomiting  continues  beyond  the  commencement  of  this  stage,  but  its 
cessation  is  not  followed  by  any  desire  either  for  food  or  drink.  The 
bowels  usually  become  even  more  constipated  than  they  were  before, 
and  the  evacuations  continue  quite  as  unnatural,  while  all  flatus  dis- 
appears from  the  intestines,  and  the  abdomen  thus  acquires  that 
shrunken  form  on  which  much  stress  has  been  laid  by  some  writers  as 
characteristic  of  hydrocephalus. 

The  transition  from  this  to  the  third  stage  of  the  disease  is  some- 
times effected  very  gradually  by  the  deepening  of  the  state  of  drowsiness, 
till  it  amounts  to  a  stupor,  from  which  it  is  impossible  to  rouse  the  child. 
At  other  times,  however,  this  stupor  comes  on  very  suddenly,  succeed- 
ing immediately  to  an  attack  of  convulsions.  These  convulsions  usually 
affect  one  side  much  more  than  the  other,  and  after  the  fit  has  passed 
off  one  side  is  generally  found  partially  or  completely  paralysed,  while 
the  child  makes  constant  automatic  movements  with  the  other,  carrying 
the  hand  to  the  head,  and  alternately  flexing  and  extending  the  leg. 
The  side  which  is  the  most  affected  during  the  fit  is  generally,  though 
not  invariably,  the  most  palsied  afterwards.  When  the  third  stage  is 
fully  established,  the  child  lies  upon  its  back  in  a  state  of  complete 
insensibility,  with  one  leg  stretched  out,  the  other  drawn  up  towards 
the  abdomen.  The  tremulous  hands  are  either  employed  in  picking 
the  lips  or  nose  till  the  blood  comes,  or  one  hand  is  kept  on  the  genitals 
while  the  other  is  rubbing  the  face  or  head.  The  head  is  at  one 
moment  hot,  and  the  face  flushed,  and  then  the  heat  disappears  and 
the  flush  fades,  though  usually  there  is  a  permanent  increase  in  tem- 
perature about  the  occiput.  Sometimes  the  skin  is  dry,  and  then, 
though  the  extremities  are  cold,  a  profuse  sweat  breaks  out  on  some 
part  of  the  body  or  on  the  head.  The  pulse  often  loses  its  irregularity, 
but  at  the  same  time  it  grows  smaller  and  more  rapid,  till  at  length  it 
can  be  counted  only  at  the  heart.  The  eyelids  now  close  only  very 
partially,  and  in  most  cases  there  is  some  degree  of  strabismus.  Light 
is  no  longer  unpleasant,  for  the  dilated  pupils  are  either  altogether 
motionless,  or  they  act  very  sluggishly,  frequently  oscillating  under 
the  stimulus  of  a  bright  light,  alternately  contracting  and  dilating,  till 
at  length  they  subside  into  their  former  dilated  condition.  The  child 
now  often  makes  automatic  movements  with  its  mouth,  as  though 
chewing,  or  as  though  endeavouring  to  swallow  something.  It  gen- 
erally happens  that,  although  sensibility  is  quite  extinguished,  the 
child  will  still  swallow  anything  that  is  put  into  its  mouth,  and  the 
power  of  deglutition  is  in  most  cases  one  of  the  very  last  to  be 
abolished. 

An  attack  of  convulsions  now  sometimes  puts  an  end  to  the  painful 
scene ;  but  often  the  child  lives  on  for  days,  though  wasted  to  a  skele- 
ton, and  its  features  so  changed  by  suffering  that  those  persons  who  had 
seen  it  but  a  short  time  before  would  now  scarcely  recognise  it.  The 
head  often  becomes  somewhat  retracted,  and  the  child  bores  with  the 
occiput  in  the  pillow;  the  eyelids  are  wide  open,  and  the  eyes  turned 
upwards  so  as  to  conceal  three-fourths  of  the  iris  beneath  the  upper  lid, 


ACUTE   HYDROCEPHALUS —  09 

while  the  countenance  is  still  further  disfigured  by  a  horrible  squint,  or 
by  a  constant  rolling  of  the  eyes.  The  pupils  are  now  fixed  and  glassy, 
the  white  of  the  eyes  is  extremely  bloodshot,  and  their  surface  is  be- 
smeared with  a  copious  secretion  from  the  Meibomian  glands  which  col- 
lects in  their  corners.  One  leg  and  arm  are  stiff  and  motionless,  the 
other  in  constant  spasmodic  movement,  while  the  hands  are  often 
clenched  and  the  wrists  bent  upon  the  forearm.  At  the  same  time  there 
is  frequently  so  much  subsultus  as  to  render  it  impossible  to  count  the 
pulse,  and  the  muscles  of  the  face  are  thrown  from  time  to  time  into  a 
state  of  spasmodic  twitching.  Cold  clammy  sweats  break  out  abun- 
dantly about  the  head,  the  breathing  is  laboured,  deglutition  becomes 
difficult,  and  the  child  almost  chokes  with  the  effort  to  swallow,  or  lets 
the  fluid  run  out  at  the  corners  of  its  mouth.  It  is  uncertain  how  long 
this  condition  may  endure:  the  recurrence  of  convulsions  usually 
hastens  the  end,  but  sometimes  many  days  will  pass,  during  which 
death  is  hourly  expected,  and  earnestly  prayed  for,  to  put  an  end  to 
the  patient's  sufferings. 


LECTURE    VI. 


Acute  Hybkocephalus,  continued.  Diversities  in  its  course  and  in  its  modes  of 
attack — insidious  approach  in  phthisical  subjects — resemblance  of  its  symptoms 
to  those  of  remittent  fever — of  simple  gastric  disorder — serious  import  of  continued 
sickness  in  cases  of  gastric  disorder. 

Prognosis.  Disease  almost  always  fatal — appearances  of  improvement  often  delusive — 
cautions  against  being  misled  by  them. 

Duration  of  the  disease — real  nature  of  cases  of  waterstroke. 

Treatment. — Prophylaxis — Treatment  of  the  disease — rules  for  depletion,  for  use  of 
purgatives,  mercurials,  application  of  cold. — Diet  of  patients — circumstances  under 
which   opiates  may  be  useful — when  blisters  are  to  be  applied.     Conclusion. 

It  can  scarcely  be  necessary  to  observe  that  acute  hydrocephalus  does 
not  always  run  precisely  that  course  which  I  described  to  you  at  our 
last  meeting.  Almost  every  case,  indeed,  presents  some  slight  peculi- 
arity, either  in  the  comparative  severity  of  the  different  symptoms,  in 
the  date  of  their  occurrence,  or  in  the  order  in  which  they  succeed  each 
other.  Convulsions,  for  instance,  though  hardly  ever  absent,  occur 
earlier  in  one  case  than  in  another, — affect  in  one  the  whole  body,  in 
another  are  limited  to  one  side, — are  succeeded  in  one  instance  by 
paralysis,  in  another  by  a  stiff  and  contracted  state  of  the  limbs.  Again, 
coma  sometimes  comes  on  gradually,  at  other  times  takes  place  sud- 
denly ;  in  one  instance  it  continues  long,  in  another  is  speedily  followed 
by  death.  The  pupils  sometimes  become  early  insensible  to  light ;  at 
other  times  they  continue  to  act,  though  slowly,  almost  to  the  time  of 
death ;  and  in  like  manner  strabismus  may  exist  in  various  forms,  or 
there  may  be  constant  rotation  of  the  eyeball,  or  neither  of  these  symp- 
toms may  be  present ;  and  yet  we  cannot  couple  these  diversities  in 
the  signs  of  the  disease  with  any  certain  differences  in  the  morbid  ap- 


70  DIAGNOSIS   OF   HYDROCEPHALUS. 

pearances.  But,  how  much  soever  one  case  of  hydrocephalus  may 
differ  from  another  in  these  respects,  such  differences  are  of  compara- 
tively hut  little  moment,  since,  whether  these  symptoms  occur  early  or 
late, — whether  they  are  slight  or  severe, — short  in  their  duration,  or  of 
long  continuance, — the  appearance  of  any  one  of  them  stamps  the 
character  of  the  disease  too  plainly  for  it  to  be  mistaken,  and  indicates 
not  the  incipient,  but  the  fully  developed  evil.  The  deviations  from 
the  ordinary  mode  of  its  attack  are  far  more  important,  since  they  may 
lead  you  to  mistake  the  nature  of  the  disease  during  the  only  time 
when  treatment  is  likely  to  be  of  much  avail. 

The  healthy  and  robust  are  comparatively  seldom  attacked  by  hydro- 
cephalus, and  in  many  instances  the  indications  of  declining  health 
precede  for  weeks  or  months  the  real  premonitory  symptoms  of  the 
disease.  You  may,  however,  be  so  much  taken  up  with  watching  the 
former  as  to  overlook  the  latter,  or  to  misinterpret  their  meaning.  Your 
solicitude  is  excited  by  the  gradual  decay  of  a  child's  strength,  and  the 
wasting  of  its  flesh.  You  observe  that  it  becomes  subject  to  irregular 
febrile  attacks, — that  it  coughs  a  little, — that  it  loses  its  appetite, — that 
its  bowels  are  almost  always  disordered,  and  generally  constipated, — 
and  that  it  makes  frequent  vague  complaints  of  pains  in  its  limbs,  or  of 
weariness  or  headache.  These  symptoms,  which  depend  upon  that  ge- 
neral deposit  of  tubercle  in  the  different  organs  of  the  body  which 
almost  every  dissection  of  fatal  cases  of  hydrocephalus  reveals,  make 
you  apprehensive  lest  phthisis  be  about  to  come  on,  and  you  often  aus- 
cultate the  chest  in  the  expectation  of  discovering  some  signs  of  disease 
in  the  lungs.  At  length,  the  child  seems  worse, — he  coughs  more,  and 
is  more  feverish, — grows  heavier  and  more  dull,  but  does  not  complain 
more  about  his  head, — or,  at  most,  says  that  the  cough  makes  his  head 
ache.  The  parent  thinks  the  child  must  have  caught  cold,  and  you  do 
not  see  the  indication  of  any  new  disorder ;  for  though  listless  and 
moody,  he  still  moves  about  in  the  house,  and  sometimes  plays,  though 
in  a  spiritless  manner.  Simple  treatment  seems  to  do  a  little  good,  and 
you  not  unnaturally  hope  that  the  aggravation  of  the  symptoms  will 
prove  only  temporary  ;  but  after  an  usually  restless  night,  a  fit  of  con- 
vulsions comes  on,  or  the  listlessness  deepens  in  the  course  of  a  few 
hours,  and  without  any  evident  cause,  into  profound  coma,  and  a  very 
few  days  terminate  the  patient's  life. 

In  such  a  case  as  this,  you  would,  it  is  true,  most  likely  be  able  to  do 
little  or  nothing,  even  if  you  recognised  the  approach  of  hydrocephalus 
from  the  earliest  indication  of  its  coming.  But  you  would  save  your 
patient's  friends  some  sorrow,  and  yourself  some  reproach,  if  you  disco- 
vered the  danger  at  a  distance.  Now,  whenever  any  child,  especially 
if  it  be  of  a  consumptive  family,  has  been  failing  in  health  for  some 
weeks  or  months,  without  evident  cause,  I  advise  you  to  look  with  much 
suspicion  on  the  supervention  of  unusual  drowsiness  or  listlessness,  or 
on  any  aggravation  of  the  cough,  for  which  you  cannot  find  adequate 
reason  in  the  information  afforded  by  auscultation.  A  frequent,  short, 
dry  cough  is  not  infrequent  at  the  commencement  of  hydrocephalus ; 
but  in  cases  where  cough  has  existed  for  some  time,  you  are  very  likely 
to  refer  its  aggravation  to  mischief  in  the  chest,  and  to  lose  sight  of 


DIAGNOSIS   Or   HYDROCEPHALUS.  71 

its  possible  connection  with  affection  of  the  brain.  Inquire,  therefore, 
in  every  doubtful  case,  whether  there  has  been  any  vomiting, — for  some- 
times it  is  but  slight,  and  occurs  only  after  food  has  been  taken,  and 
then  only  occasionally,  so  that  it  may  seem  to  the  parents  to  be  a  symp- 
tom of  little  importance.  Ascertain  the  condition  of  the  bowels  ;  watch 
the  pulse  most  carefully;  it  may  not  be  irregular  nor  intermittent, but 
you  will  probably  find  a  little  inequality  in  the  force  and  duration  of 
its  beats ;  if  so,  you  may  be  sure  that  the  head  is  suffering,  and  if  the 
head  suffer  in  such  a  patient,  it  is  ninety-nine  cases  out  of  a  hundred 
from  the  approach  of  hydrocephalus.  Do  not  content  yourself  with 
seeing  your  patient  once  a  day;  visit  him  at  least  morning  and  even- 
ing,— stay  sometime  with  him,  watch  him  closely,  and  see  how  far  he 
is  capable  of  being  amused ;  but  if  you  be  still  strangers  to  that  free- 
masonry which  assures  a  little  child  that  you  love  it,  you  will  very 
likely  fail  of  arriving  at  the  truth. 

But  it  may  happen  that  a  child,  though  not  robust,  had  yet  been  to- 
lerably well  till  a  week  or  two  before  you  visited  it,  and  that  it  was  then 
attacked  with  febrile  symptoms,  with  a  little  headache,  and  perhaps  with 
vomiting  and  constipation.  You  learn  that  these  two  symptoms  were 
but  of  short  duration,  but  that  the  fever  has  continued  ever  since,  and 
that  the  child  has  been  very  taciturn,  rather  drowsy,  and  averse  to 
being  disturbed,  though  giving  rational  answers  when  spoken  to.  You 
regard  the  case  as  one  of  remittent  fever,  and  treat  it  without  either  im- 
provement or  deterioration,  till  the  appearance  of  convulsions  or  coma 
corrects  your  diagnosis,  though  unfortunately  too  late. 

It  must  be  confessed  that  it  is  sometimes  a  matter  of  great  difficulty 
to  distinguish  between  these  two  affections.  It  may  help  you,  indeed, 
to  bear  in  mind  that  remittent  fever  is  very  rare  before  five  years  of 
age,  and  is  hardly  ever  met  with  in  children  under  three  ;  while  at 
least  half  of  all  cases  of  hydrocephalus  occur  in  children  who  have  not 
completed  their  fifth  year.  But  still  this  is  not  the  kind  of  evidence 
on  which  you  can  place  much  reliance  in  a  doubtful  case.  There  are 
differences  in  the  symptoms,  however,  which  will  generally  enable  you 
to  discriminate  between  them,  if  you  have  acquired  the  habit  of  minute 
and  careful  observation.  The  vomiting,  on  which  I  have  laid  so  much 
stress  as  a  symptom  of  .approaching  hydrocephalus,  is  often  absent  even 
at  the  onset  of  remittent  fever ;  it  soon  ceases,  and  is  not  followed  by 
that  abiding  nausea  which  is  frequent  in  hydrocephalus.  In  remittent 
fever  the  bowels  are  often  relaxed  from  the  very  outset,  or  speedily  be- 
come so,  and  the  evacuations  present  no  resemblance  to  the  scanty, 
dark,  or  mud  coloured  motions  which  are  voided  in  hydrocephalus,  but 
are  usually  watery,  faecal,  and  of  a  lightish  colour.  Tenderness  of  the 
abdomen  is  nearly  constant  in  remittent  fever,  and  is  greater  in  the  iliac 
regions  than  elsewhere,  and  wind  can  always  be  felt  in  the  intestines. 
The  tongue  is  not  moist  as  in  hydrocephalus,  and  is  seldom  much 
loaded,  but  has  in  general  only  a  thin  coating  of  yellow  fur  at  the  centre 
and  towards  the  root,  while  it  is  very  red  at  the  tip  and  edges,  and  be- 
comes dry  at  an  early  stage  of  the  disease.  In  hydrocephalus  there  is 
frequently  a  great  distaste  for  drink  as  well  as  for  food,  while  although 
the  appetite  is  lost  in  cases  of  remittent  fever,  yet  the  patients  have 


72  DIAGNOSIS   OF   HYDROCEPHALUS. 

great  desire  for  drink,  especially  for  cold  drink,  to  quench  the  urgent 
thirst.  The  heat  of  the  skin  in  remittent  fever  is  extremely  pungent, 
and  much  greater  than  in  hydrocephalus,  in  which,  although  there  is 
great  dryness  of  the  surface,  yet  the  temperature  is  seldom  much  in- 
creased. The  pulse  in  remittent  fever  is  much  quicker  than  in  hydro- 
cephalus ;  it  continues  quick  throughout,  and  never  becomes  unequal 
or  irregular,  while  its  frequency  is  in  direct  proportion  to  the  elevation 
of  the  temperature  of  the  surface.  In  remittent  fever  the  child  makes 
few  complaints  about  its  head,  but  delirium  is  of  early  occurrence,  espe- 
cially at  night ;  in  hydrocephalus,  on  the  contrary,  true  delirium  hardly 
ever  occurs  till  an  advanced  period  of  the  disease,  and  is  sometimes  ab- 
sent altogether.  In  remittent  fever,  as  its  name  implies,  there  are 
distinct  remissions  and  exacerbations  of  the  symptoms,  the  patient  get- 
ting better  towards  morning,  and  worse  again  as  night  approaches; 
while,  though  there  are  many  fluctuations  in  the  course  of  hydrocepha- 
lus, yet  we  observe  no  definite  periods  at  which  the  symptoms  invariably 
remit  or  are  increased  in  severity. 

With  due  caution  you  will  scarcely  take  a  case  of  incipient  hydro- 
cephalus for  one  of  simple  gastric  disorder,  though  there  are  many 
points  of  resemblance  between  the  two.  Vomiting  and  constipation 
occur  in  both,  and  there  is  usually  some  degree  of  headache  in  the 
latter  affection,  though  seldom  severe  or  lasting.  Mere  gastric  dis- 
order is  not  attended  with  much  febrile  disturbance ;  the  face,  though 
heavy,  is  not  distressed  nor  anxious,  while  the  tongue  is  usually  much 
more  coated  than  at  the  onset  of  an  attack  of  hydrocephalus.  The 
relief  that  follows  the  use  of  remedies  in  the  less  dangerous  affection 
is  complete  as  well  as  speedy ;  the  sickness  will  cease  after  the  opera- 
tion of  an  emetic,  the  bowels  will  act  copiously  after  the  administration 
of  a  brisk  purgative,  and  in  a  day  or  two  your  patient  will  be  quite 
well.  The  persistence  of  vomiting,  however,  in  any  case  which  you 
had  thought  to  be  one  merely  of  gastric  disorder,  must  be  looked  upon 
by  you  with  great  suspicion,  and  this  even  though  the  bowels  have 
acted  freely  from  medicine,  and  though  there'be  no  obvious  indication 
of  mischief  in  the  head.  I  once  saw  a  case  in  which  the  continuance 
of  intractable  vomiting  for  more  than  six  weeks  after  the  cessation  of 
a  short  but  severe  attack  of  diarrhoea,  was  the  only  symptom  of  illness 
in  a  boy  five  years  of  age.  At  length  he  became  a  little  drowsy,  and 
once  or  twice,  when  closely  questioned,  said  that  his  head  ached.  Not 
quite  two  days  after  the  first  complaint  of  headache,  the  child  had  a 
violent  fit  of  convulsions,  and  in  the  course  of  the  succeeding  week  he 
died,  having  suffered  during  that  time  from  all  the  symptoms  of  acute 
hydrocephalus,  and  his  body  presenting  after  death  its  characteristic 
lesions. 

An  inquiry  of  little  less  importance  than  that  concerning  the  means 
of  distinguishing  between  one  disease  and  another,  respects  the  prog- 
nosis  that  we  are  to  form,  the  inferences  that  we  may  draw,  from  the 
course  of  the  malady,  either  to  encourage  hope  or  to  excite  anxiety. 
Unfortunately  the  prognosis  in  hydrocephalus  is  so  unfavourable  that 
we  can  scarcely  speak  of  the  circumstances  which  regulate  it ;  for 
under  almost  every  variety  of  condition,  of  symptoms,  and  of  treat- 


PROGNOSIS  OF  HYDROCEPHALUS.  73 

ment,  the  patients  die.  I  have  never  yet  seen  an  instance  of  recovery 
from  advanced  hydrocephalus;  I  have  seen  but  one  in  which  the  child 
got  well  after  the  disease  was  well  marked  and  the  second  stage  had 
commenced,  and  have  observed  only  very  few  cases  have  a  favourable 
issue  even  though  they  came  under  treatment  immediately  on  the 
appearance  of  the  premonitory  symptoms  of  water  on  the  brain.  This 
result  is,  I  know,  more  discouraging  than  that  which  other  practi- 
tioners have  arrived  at ;  but  I  regret  that  additional  experience  since 
I  first  made  this  statement  does  not  enable  me  to  modify  it;  and 
M.  Guersant,  of  Paris,  who  probably  had  seen  more  than  any  man 
now  living  of  children's  diseases,  does  not  seem  to  have  been  more 
fortunate. 

"  Tubercular  meningitis,"vsays  he  (by  which  name  French  writers 
have  designated  the  disease  that  we  are  now  studying),  "  may  some- 
times terminate  by  recovery  in  the  first  stage,  though  the  nature  of 
such  cases  is  always  more  or  less  doubtful ;  in  the  second  stage  I  have 
not  seen  one  child  recover  out  of  a  hundred,  and  even  those  who 
seemed  to  have  recovered  have  either  sunk  afterwards  under  a  return 
of  the  same  disease  in  its  acute  form,  or  have  died  of  phthisis.  As  to 
patients  in  whom  the  disease  has  reached  the  third  stage,  I  have  never 
seen  them  improve  even  for  a  moment."* 

Since  the  fatality  of  the  disease  is  so  invariable,  it  may  seem  to  you 
superfluous  for  me  to  say  anything  more  with  reference  to  the  prog- 
nosis ;  but  I  am  desirous  of  guarding  you  against  being  deceived  by 
certain  delusive  appearances  of  improvement  which  are  by  no  means 
unusual  even  in  cases  where  the  real  nature  of  the  disease  has  for  some 
two  or  three  days  been  clearly  manifested.  A  few  years  ago,  a  little 
girl,  three  years  old,  was  brought  to  me  in  a  state  of  profound  coma, 
and  presenting  the  symptoms  of  the  third  stage  of  acute  hydrocephalus, 
of  which  she  died  forty-eight  hours  afterwards,  without  having  had  any 
return  of  consciousness.  I  learned  from  the  mother  that,  fourteen  day 
previously,  the  child  had  been  attacked  with  vomiting,  attended  with 
fever  and  great  drowsiness ;  but  that  these  symptoms  abated  in  three 
days,  and  that  the  child  improved  and  was  regaining  her  cheerfulness 
until  the  morning  of  the  day  before  she  was  brought  to  me,  when  her 
mother  found  her  comatose,  and  in  just  the  condition  in  which  she  was 
when  I  saw  her.  A  more  acute  observer  than  this  child's  mother  would 
probably  have  seen  something  to  make  her  mistrust  the  apparent  im- 
provement ;  but  it  is  evident  that  the  change  was  great  from  fever  and 
drowsiness,  and  frequent  vomiting,  to  a  cessation  of  the  sickness,  a 
diminution  of  the  fever,  and  a  return  of  cheerfulness  ;  and  yet  during 
all  this  time  disease  was  going  on,  and  producing  the  very  extensive 
softening  of  the  central  and  posterior  parts  of  the  brain  which  was  dis- 
covered after  death.  The  cases  in  which  you  are  likely  to  fall  into  error 
are  for  the  most  part  such  as  have  come  on  insidiously,  unattended  with 
very  violent  symptoms,  and  about  which  you  perhaps  hesitated  some 
little  time  before  you  became  convinced  that  so  grave  a  malady  as 

1  Diet.   Med.  t.  xix.  p.  403;  quoted  by  MM.  Eilliet  and  Barthez,  op.  cit.  t.  iii. 
p.  631. 


74  DELUSIVE   APPEARANCES   OF   IMPROVEMENT. 

hydrocephalus  could  wear  so  mild  a  form.  Treatment  for  some  days 
produces  no  effect,  the  disease  remaining  stationary ;  but  at  length 
your  hopes  are  raised  by  finding  that  the  vomiting  has  ceased,  and 
that  the  constipated  condition  of  the  bowels  has  been  overcome.  The 
heat  of  head  has  disappeared,  the  pulse  presents  much  less  irregularity 
than  before,  or  may  even  have  lost  it  altogether  ;  and  the  child's  rest- 
lessness has  subsided,  and  its  manner  is  almost  natural.  Perhaps  the 
child  seems  rather  drowsy,  or  it  may  be  sleeping  at  the  time  of  your 
visit ;  but  the  account  you  hear  of  it  seems  satisfactory  :  its  repose  is 
quiet,  and  the  mother  rejoices  :  her  little  one  has  had  no  sound  sleep 
for  many  days,  and  will,  she  thinks — and  you  may  think  so  too — be 
much  better  when  it  awakes.  It  does  not  wake  up,  but  swallows  well 
when  some  drink  is  given  in  a  spoon,  and  the  mother  is  still  content. 
Presently  slight  twitches  of  the  face  and  hands  are  seen,  but  the  child 
does  not  awake, — you  cannot  rouse  it :  the  sleep  has  passed  into  coma, 
and  the  coma  will  end  in  death.  Always  suspect  the  sleep-  which 
follows  continued  restlessness  in  a  case  of  hydrocephalus. 

In  other  cases,  although  the  disease  did  not  come  on  so  insidiously, 
and  although  it  has  reached  a  stage  at  which  all  its  characters  are  well 
marked,  you  may  yet  be  led  for  a  few  hours  to  entertain,  and  perhaps  to 
express,  ill-founded  hopes,  in  consequence  of  the  symptoms  having  some- 
what abated,  of  the  child  having  had  some  hours  of  quiet  sleep,  or  having 
ceased  to  vomit,  or  no  longer  complaining  of  its  head,  or  being  visited  by 
a  short  gleam  of  cheerfulness.  You  must  not  forget,  however,  that  it 
is  characteristic  of  hydrocephalus  to  present  irregular  remissions,  that 
they  last  but  for  a  few  hours,  and  that  at  your  next  visit  you  may  find 
every  bad  symptom  returned,  and,  possibly,  some  fresh  one  superadded. 
Usually,  too,  you  may  be  guarded  from  error  by  observing  the  sudden- 
ness of  the  change,  and  that  the  condition  which  has  now  come  on  is 
the  very  opposite  of  that  which  before  existed,  preternatural  excitement 
having  been  succeeded  by  an  equally  unnatural  apathy,  or  great  talk- 
ativeness having  taken  the  place  of  obstinate  silence,  or  the  pulse, 
which  before  was  above  120,  having  sunk  all  at  once  to  90  in  the  minute. 
At  other  times,  though  there  is  a  general  abatement  in  all  the  previous 
symptoms,  yet  some  new  one  may  have  appeared ;  not  more  formidable, 
perhaps,  than  the  occurrence  of  a  slight  degree  of  strabismus  which 
had  not  existed  before,  but  still  enough  to  indicate  that  the  mischief  is 
still  going  on,  and  that  you  must  not  dare  to  hope. 

A  still  more  remarkable  temporary  improvement  is  sometimes 
observed,  that  "  lightning  before  death"  which  seems,  contrary  to  all 
expectation,  to  warrant  a  hope  of  recovery  even  when  dissolution  is 
impending.  The  only  instance  of  it  which  has  come  under  my  notice 
occurred  in  a^girl,  aged  seven  years,  who  died  on  the  fifteenth  day  of 
an  attack  of  acute  hydrocephalus.  She  had  been  in  a  state  of  stupor 
for  six  days,  and  profoundly  comatose  for  two  days,  when  she  became 
conscious,  swallowed  some  drink,  spoke  sensibly,  and  said  she  knew  her 
father.  She  became  worse  again,  however,  in  the  course  of  an  hour 
and  a  half,  though  she  did  not  sink  into  the  same  deep  coma  as  before, 
and  in  another  hour  she  died. 

A  few  points  still  remain  on  which  I  must  touch  before  passing  to  the 


DURATION  Or  ACUTE  HYDROCEPHALUS.  75 

consideration  of  the  treatment  of  hydrocephalus.  One  of  these  is  the 
question  of  its  duration.  The  exact  determination  of  this  is  not  always 
easy,  owing  to  the  insidious  manner  in  which  the  disease  comes  on ;  but, 
on  the  whole,  there  is  less  discrepancy  than  might  have  been  expected 
between  the  statements  of  different  writers.  Of  117  cases  observed  or 
collected  by  Dr.  Hennis  Green,  80  terminated  within  14  days,  and  111 
within  20  days.  Of  28  cases  reported  by  Golis,1  18  terminated  within 
14  days,  and  only  2  exceeded  20  days.  MM.  Rilliet  and  Barthez,* 
state  the  average  duration  of  28  cases  that  came  under  their  observa- 
tion to  have  been  22  days ;  and  the  average  duration  of  34  fatal  cases 
of  which  I  have  a  complete  record,  was  20  days.  Of  these  84  cases, 
that  which  ran  the  most  rapid  course  terminated  fatally  in  five  days  ; 
death  took  place  in  11  more  before  the  fourteenth  day ;  in  14  others 
during  the  third  week,  and  in  3  during  the  fourth  week.  In  the  remain- 
ing five  cases  indications  of  cerebral  disturbance  had  existed  for  four, 
six,  or  eight  weeks ;  ,but  death  took  place  in  every  instance  in  less  than 
21  days  after  the  appearance  of  well-marked  symptoms  of  hydrocephalus. 
We  are,  then,  warranted  in  stating  that  the  disease  usually  runs  its 
course  in  from  two  to  three  weeks. 

The  late  celebrated  Dr.  Golis,  of  Vienna,  proposed  the  name  of  toater- 
stroke  for  some  cases  in  which  the  head  symptoms  were  of  such  short 
duration  as  not  to  exceed  24  or  48  hours.  Such  a  rapid  course,  how- 
ever, is  not  observed  in  true  tuberculous  hydrocephalus ;  but  the  name 
of  water-stroke  has  been  applied  to  a  great  variety  of  cases  which  have 
presented  little  in  common  except  the  presence  of  head  symptoms,  and 
their  rapidly  fatal  termination.3  The  appellation  has  been  sometimes 
bestowed  on  cases  of  intense  cerebral  congestion  ;  at  other  times  on 
cases  of  simple  meningitis.  In  a  few  instances  the  name  may  have  been 
given  to  cases  of  true  hydrocephalus  in  which  the  rapid  course  of  ths 
disease  has  been  apparent,  rather  than  real,  owing  to  its  having  succeeded 
to  chicken-pox,  or  come  on  in  the  course  of  that  febrile  disturbance 
which  vaccination  sometimes  excites,  or  which  attends  upon  dentition. 
Under  such  circumstances  it  often  happens  that  the  manifestations  of 
cerebral  diseases  are  mistakenly  attributed  entirely  to  the  previous 
cause  of  irritation  in  the  system,  so  that,  when  the  signs  of  serious 
mischief  force  themselves  upon  the  notice,  the  hydrocephalus  has  well 
nigh  run  its  course. 

In  describing  this  disease  I  divided  it  into  three  stages,  but  did  so 
simply  for  convenience.  Many  physicians,  however,  have  attached  much 
greater  importance  to  this  division,  regarding  the  first  as  the  stage  of 
turgescence ;  the  second  as  that  of  inflammation ;  the  third,  that  of 
effusion.  Again,  the  first  has  been  characterised  as  the  stage  of  increased 
sensibility ;  the  second,  of  diminished  sensibility  ;  the  third,  of  palsy. 
Lastly,  Dr.  Whytt  proposed  a  division  that  has  been  much  followed, 
based  on  the  variations  of  the  pulse,  which  is  usually  quick  and  regular 
in  the  first  stage,  slow  and  irregular  in  the  second,  and  quick  in  the 

1  Praktische  Abhandlungen,  etc.     8vo.     Wien,  1820.     Vol.  i. 

2  Op.  cit.  vol.  iii.  p.  497. 

3  In  proof  of  this  statement,  see  Golis,  lib.  cit.  Cases  1  to  9. 


76  THE   THREE    STAGES   OF   HYDROCEPHALUS. 

third.  There  are  too  many  exceptions,  however,  to  the  order  of  these 
changes,  for  it  to  he  right  to  make  them  the  foundation  of  any  division 
of  the  disease  into  different  stages;  and  the  same  remark  may  he  made 
with  reference  to  any  arrangement  founded  on  the  variations  in  the 
sensibility  of  the  patient. 

I  have  said  that  the  phenomena  of  the  pulse  are  not  constant:  I  need 
scarcely  add,  that  the  slow  irregular  pulse  is  no  proof  of  the  occurrence 
of  effusion ;  neither  is  the  dilated  pupil  a  proof  of  it :  it  is  a  proof  of 
great  mischief  having  been  inflicted  on  the  brain :  so  are  the  strabismus 
and  the  rolling  of  the  eyes  which  frequently  accompany  it ;  but  you 
cannot  connect  these  symptoms  with  injuries  of  a  special  kind,  or 
involving  particular  parts  of  the  brain. 

Although  a  disease  of  childhood,  acute  hydrocephalus  is  by  no  means 
most  frequent  in  early  infancy.  In  only  five  of  36  fatal  cases  in  which 
the  diagnosis  was  confirmed  by  a  post-mortem  examination,  were  my 
patients  under  a  year  old ;  9  were  under  3  years  of  age ;  18  between  3 
and  6;  3  between  6  and  9;  and  1  between  10  and  11  years  old.1 

From  all  that  I  have  told  you  about  hydrocephalus,  you  have,  I  doubt 
not,  already  deduced  the  practical  inference,  that  the  only  treatment 
likely  to  avail  much  is  the  prophylactic  ;  and  that,  if  you  would  hope 
ever  to  save  a  patient,  you  must  treat  the  mere  threatenings  of  his  dis- 
ease, and  not  remain  inactive  until  you  see  the  malady  fully  developed 
before  you. 

The  prophylactic  treatment  of  hydrocephalus  must  be  in  the  main  the 
prophylactic  treatment  of  consumption,  since  not  only  is  tubercle  inva- 
riably present  in  the  various  organs  of  children  who  have  died  of  hydro- 
cephalus, but  the  disease  itself  often  supervenes  on  more  or  less  definite 
phthisical  symptoms.  The  influence  of  hereditary  predisposition  to 
phthisis,  in  favouring  the  development  of  hydrocephalus,  is  shewn  by 
the  fact  that  not  only  was  the  previous  health  of  the  children  indifferent 
in  two-thirds  of  the  cases  that  came  under  my  notice,  but  that,  in 
sixteen  out  of  twenty  instances,  in  which  the  health  of  the  relatives  was 
made  the  subject  of  special  inquiry,  it  was  ascertained  that  either  the 
father,  mother,  aunt,  or  uncle,  had  died  of  phthisis. 

In  any  case  where  several  children  of  the  same  family  have  already 
died  of  hydrocephalus,  or  have  shewn  a  marked  tendency  to  the  disease, 
the  mother  should  for  the  future  abstain  from  suckling  her  infants,  and 
they  should  be  brought  up  by  a  healthy  wet-nurse.  Under  such  circum- 
stances, too,  it  would  be  desirable  that  a  child  should  always  live  in  the 
country;  its  clothing  should  be  warm,  and  flannel  should  be  worn  next 
the  skin.  Its  diet  should  be  simple,  and  any  change  in  it  should  be 
made  with  the  greatest  caution,,  while  milk  should  for  a  long  time  form 
one  of  its  chief  aliments ;  and  it  would  be  desirable  not  to  wean  it  until 
after  it  had  cut  four  molar  teeth,  as  well  as  all  the  incisors.  As  it  grows 

1  This  statement  as  to  the  time  of  life  at  which  hydrocephalus  is  most  frequent  is 
fully  borne  out  by  the  Fifth  and  Eighth  Reports  of  the  Registrar-General,  from  which 
it  appears  that  while  only  7  per  cent,  of  the  total  deaths  under  one  year  old  in  this 
metropolis  resulted  from  cephalitis  and  hydrocephalus,  these  diseases  caused  12.5  per 
cent,  of  the  deaths  between  1  and  3:  12.5  per  cent,  of  those  between  3  and  5;  11.1 
per  cent,  of  those  between  5  and  10 ;  and  5  9  per  cent,  of  those  between  10  and  15. 


PROPHYLACTIC   TREATMENT   OF   HYDROCEPHALUS.  77 

up,  over-exertion,  either  of  mind  or  body,  must  be  most  carefully 
avoided  ;  and  on  this  account,  though  free  exercise  in  the  air  is  highly 
beneficial,  gymnastic  exercises  are  by  no  means  to  be  recommended. 
The  child  must  be  watched  carefully  during  the  whole  period  of  denti- 
tion, and  every  precaution  must  be  taken  to  shield  it  from  the  contagion 
of  measles,  hooping-cough,  or  scarlatina ;  since  these  diseases,  which 
tend  to  excite  the  tuberculous  cachexy,  would  be  likely  greatly  to 
aggravate  the  disposition  to  hydrocephalus,  or  even  to  bring  on  an 
attack  of  the  disease.  The  condition  of  the  bowels  must  be  most  care- 
fully watched ;  constipation  must  not  be  allowed  to  exist  even  for  a 
day,  and  the  least  indication  of  gastric  disorder  must  be  regarded  as  a 
serious  matter.  It  is  not  desirable  that  calomel  should  be  used  as  a 
domestic  remedy ;  but  if  the  simplest  aperients  (such  as  castor-oil,  or 
the  infusion  of  senna,  or  of  rhubarb1)  do  not  act,  the  child  should  be 
immediately  placed  under  proper  medical  care.  If  at  any  time  there 
should  be  heat  of  head,  and  the  child  appear  squeamish,  you  must  be 
at  hand  with  your  remedies,  and  those  well  chosen.  Any  bulky  remedy 
would  probably  be  rejected  ;  but  the  stomach  is  almost  sure  to  bear  a 
grain  or  two  of  calomel  with  sugar,  and  you  may  follow  this  up  with 
small  quantities  of  the  sulphate  of  magnesia2  every  hour  until  the 
bowels  act  freely.  A  small  dose  of  mercury  and  chalk,  or  of  calomel, 
may  be  continued  every  night  for  two  or  three  times ;  and  if  any  fever- 
ishness  remain,  or  the  bowels  be  disposed  to  be  constipated,  the  sulphate 
of  magnesia  may  still  be  given  twice  or  thrice  a  day.  Leeches  should 
not  be  applied  to  the  head  without  very  obvious  necessity,  nor  then  in 
large  numbers,  for  strumous  children  do  not  bear  the  loss  of  blood  well ; 
and  your  endeavour  should  therefore  always  be,  not  simply  to  cure,  but 
to  cure  at  the  smallest  possible  expense  to  the  constitution.  After 
attacks  of  this  kind,  children  sometimes  recover  their  health  very 
slowly,  and  much  good  may  then  be  effected  by  a  judicious  use  of 
tonics.  The  infusion  of  calumba,3  with  small  doses  of  rhubarb,  is  a 
very  suitable  medicine,  and  one  which  children  generally  take  tolerably 
well.  Or  you  may  give  the  ferro-citrate  of  quinine  in  orange-flower 
water,  and  sweetened  with  the  syrup  of  orange-peel,4  while  you  secure 
the  healthy  action  of  the  bowels  by  a  grain  or  two  of  Hyd.  c.  Greta, 
combined  with  five  or  six  of  rhubarb,  administered  every  night,  or 
every  other  night. 

(No.  5.)  (No.  6.) 

1  R  Potassae  Sulphat.  gr.  xij.  2  ]$  Magnes.  Sulphat.  ^ij. 

Inf.  Rhei,  gvss.  Syr.  Aurantii,  gij. 

Trae.  Aurant.  gss.  Aquas  Carui,  gvj.  M.   gij.  omni  hora 

Aquae  Carui,  giss.     M.     ^ss.  p.  r.  n.  donee  alvus  responderet. 

For  a  child  three  years  old.  For  a  child  three  years  old. 

(No.  7.) 

3  R  Inf.  Calumbae,  51J.  gij.  4  See  Formula  No.  4,  page  34. 

Inf.  Rhei,  ^ivss. 

Trae.  Aurantii,  giss.    M.    Jjiij.  bis  die. 
For  a  child  three  years  old. 


78  TREATMENT  OF   THE   ATTACK — DEPLETION. 

If  threatenings  of  head  affection  have  frequently  occurred,  an  issue 
should  be  inserted  in  the  back  of  the  neck ;  for  the  keeping  up  a  constant 
discharge  from  the  neighbourhood  of  the  head  is  certainly  very  ser- 
viceable in  many  instances  as  a  means  of  warding  off  hydrocephalus. 
A  most  remarkable  instance  of  this  is  recorded  by  Dr.  Cheyne,  who 
mentions  that  all  the  children  in  a  numerous  family  were  carried  off  by 
water  in  the  brain,  with  the  exception  of  one,  in  whose  case  the  pre- 
caution was  adopted  of  putting  a  seton  in  the  back  of  his  neck. 

But  the  opportunity  may  not  be  afforded  you  of  adopting  this  pro- 
phylactic treatment ;  and  when  you  first  see  your  patient,  the  existence 
of  headache,  vomiting,  constipation,  and  a  quickened  pulse,  with 
perhaps  a  very  slight  inequality  in  its  beat,  may  leave  you  but  little 
doubt  as  to  the  formidable  nature  of  the  disease,  with  which  you  have 
to  contend.  In  doing  this,  there  are  three  remedies  on  which  your 
main  reliance  must  be  placed, — depletion,  purging,  and  the  adminis- 
tration of  mercury. 

With  reference  to  depletion,  you  must  not  forget  that  the  disease  in 
which  you  are  about  to  employ  it,  although  of  inflammatory  nature,  is 
inflammation  in  a  scrofulous  subject,  and  is  in  many  cases  grafted  on 
previous  organic  disease;  such  as  those  tubercular  deposits  in  the  mem- 
branes of  the  brain  which  I  have  already  described  to  you.  You 
cannot,  therefore,  hope  to  cut  short  the  affection  by  a  large  bleeding, 
but  your  object  must  be  to  take  blood  enough  to  relieve  the  congested 
brain,  and  no  more  than  is  necessary  for  that  purpose.  Avoid  preci- 
pitancy in  what  you  do,  and  do  not  let  your  apprehensions  betray  you 
into  that  over-activity  which  is  sometimes  more  fatal  to  a  patient  than 
his  disease.  If  you  feel  any  doubt  as  to  the  necessity  of  depletion, 
visit  your  patient  again  before  determining  on  it,  but  do  not  delay  that 
visit  long.  Order  a  dose  of  calomel,  to  be  followed  by  some  sulphate 
of  magnesia,  if,  as  is  most  probable,  the  bowels  be  confined,  and  return 
again  in  three  or  four  hours.  You  may  then  find  that  the  bowels  have 
acted,  and  the  sickness  has  ceased ;  that  the  head  is  cooler,  and  aches 
less,  and  that  depletion  is,  for  the  present  at  any  rate,  unnecessary. 
Or  the  child's  state  may  be  the  same,  and  you  may  still  feel  uncertain 
as  to  the  right  course.  In  that  case,  at  once  obtain  the  assistance  of 
some  other  practitioner.  This  is  the  season  when  advice  may  be  really 
useful,  for  it  is  only  at  the  outset  of  the  disease  that  its  cure  is  possible ; 
when  convulsions  have  occurred,  or  coma  is  coming  on,  your  treatment 
matters  comparatively  little,  for  the  season  of  hope  and  the  opportunity 
for  action  have  then  fled. 

Though  you  may  have  determined  on  the  propriety  of  depletion,  it 
will  be  seldom  found,  even  at  the  outset  of  the  disease,  that  the  cha- 
racter of  the  pulse  is  such  as  to  warrant  venesection.  Local  bleeding 
will  generally  answer  every  purpose,  and  the  age  and  docility  of 
the  patient  will  determine  whether  it  shall  be  performed  by  cupping  or 
by  the  application  of  leeches.  The  former  is  more  effective,  and,  from 
its  shorter  duration,  often  occasions  less  excitement  and  annoyance  than 
the  latter.  In  children  who  are  very  unmanageable,  however,  or  in 
very  young  children  or  infants,  the  employment  of  leeches  is  always 
preferable.     They  should  be  applied  to  the  vertex,  because,  if  put  on 


DEPLETION — PURGATIVES.  79 

the  temples,  they  hang  down  over  the  eyes  and  terrify  the  child ;  if 
behind  the  ears,  they  are  very  likely  to  be  rubbed  off  as  it  rolls  its 
head  from  side  to  side.  I  will  not  say  that  this  depletion  is  never  to 
be  repeated,  but  I  believe  that  in  by  far  the  greater  number  of  cases 
you  will  do  no  good  whatever  by  its  repetition,  and  the  exceptional 
cases  will  generally  be  those  in  which,  very  marked  relief  having 
followed  the  first  bleeding,  the  same  symptoms  of  congestion  of  the 
brain  appear  to  be  returning  twenty-four  or  thirty-six  hours  afterwards. 
If  you  do  not  see  the  child  until  the  second  stage  of  the  disease 
is  far  advanced, — till  general  convulsions  have  occurred,  or  twitchings 
of  the  limbs,  or  of  the  muscles  of  the  face,  an  appearance  of  extreme 
alarm,  or  a  state  of  alternate  contraction  and  dilatation  of  the  pupils, 
show  them  to  be  impending, — you  must  be  exceedingly  careful  in 
abstracting  blood.  Under  such  circumstances,  I  have  seen  convul- 
sions, to  all  appearance,  induced,  and  the  fatal  course  of  the  disease 
accelerated,  by  a  rather  free,  though  by  no  means  immoderate  loss  of 
blood. 

The  value  of  purgatives  in  the  treatment  of  hydrocephalus  can 
scarcely  be  overrated ;  but  they  must  be  given  so  as  not  merely  to 
obtain  free  action  of  the  bowels,  but  to  maintain  it  for  some  days.  After 
having  once  overcome  the  constipation,  you  will  secure  this  end  best  by 
giving  small  doses  of  a  purgative  every  four  or  six  hours.  The  admin- 
istration of  a  strong  cathartic  every  morning  will  not  answer  this  end 
nearly  so  well :  for,  independently  of  the  chance  of  its  being  rejected 
by  the  stomach,  you  will  find  that  the  dose  which  sufficed  the  first  time 
will  not  be  large  enough  the  second,  and  that  there  will  be  a  constantly 
increasing  difficulty  in  obtaining  an  evacuation.  The  nausea  and  vomit- 
ing which  at  first  stood  in  the  way  of  your  administering  any  medicine, 
are  often  so  much  relieved  by  depletion,  that  the  stomach  will  almost 
immediately  afterwards  bear  a  dose  of  calomel  and  jalap,  or  calomel 
and  scammony,  which  may  be  repeated  every  three  hours,  until  it  acts, 
while  you  at  the  same  time  endeavour  to  quicken  its  operation  by  the 
administration  of  a  purgative  enema.  There  is  no  use,  however,  in 
persevering  with  these  medicines  if  they  excite  sickness,  and  it  is  then 
better  to  give  a  single  large  dose  of  calomel  in  some  loaf  sugar,  and  to 
follow  it  up  by  a  solution  of  sulphate  of  magnesia,  which  should  be  re- 
peated at  short  intervals.  When  free  evacuation  has  been  obtained, 
the  same  salt,  in  combination  with  the  nitrate  of  potash,  will  often  keep 
up  a  free  action  of  the  bowels,  as  well  as  stimulate  the  kidneys  to  in- 
creased activity.  These  remedies  may  either  be  mixed  with  the  child's 
drink,  or  be  dissolved  in  water  flavoured  with  syrup  of  lemon  or  of 
orange  peel.1 

Hand  in  hand  with  purgatives  I  would  have  you  continue  the  admi- 
nistration of  calomel;  but  I  do  not  put  faith  in  calomel  alone,  nor  in 
the  production  of  salivation,  as  a  means  of  curing  hydrocephalus.  I 
have  seen  children  die  whose  mouths  have  been  made  sore  by  mercury, 
without  any  influence  appearing  to  have  been  thereby  exerted  on  the 
disease  ;  and  I  recollect  two  who,  at  the  time  of  their  death,  were  in  a 

1  See  Formula  No.  1,  page  30. 


80  CALOMEL  IN  HYDROCEPHALUS — LOCAL  APPLICATION   OP  COLD. 

state  of  most  profuse  salivation.  Whatever  good  I  have  seen  in  these 
cases  from  calomel  has  been  when  it  was  given  in  combination  with 
purgatives,  or  when  it  produced  a  purgative  effect. 

Let  me,  however,  again  remind  you  that  you  may  have  hydrocephalus 
combined  with  tubercular  ulceration  of  the  intestines,  and  that  in  such 
a  case  diarrhoea  may  exist  from  the  outset,  or  may  come  on  after  a 
mild  dose  of  some  aperient.  Now  and  then,  too,  without  such  a  cause, 
constipation  is  absent,  while  diarrhoea  comes  on  occasionally  in  the  far 
advanced  disease.  You  must  not,  therefore,  draw  inferences  as  to  the 
state  of  the  patient  too  exclusively  from  the  condition  of  the  bowels. 

I  insisted  much  on  the  local  employment  of  cold  when  speaking  about 
the  management  of  cases  of  cerebral  congestion.  It  is  likewise  a  very 
valuable  agent  in  the  treatment  of  hydrocephalus,  but  its  application 
requires  to  be  judiciously  regulated.  You  will  generally  find  it  of  ser- 
vice after  depletion,  for  you  have  abstracted  blood  on  account  of  the 
febrile  disturbance  and  heat  of  head,  and  other  indications  of  conges- 
tion of  the  brain,  all  of  which  cold  will  be  a  powerful  auxiliary  in  sub- 
duing. So  long  as  the  signs  of  active  congestion  of  the  brain  are  pre- 
sent, cold  will  be  of  service ;  but  it  should  not  be  employed  indepen- 
dently of  those  symptoms  which  betoken  the  existence  of  that  condition  ; 
nor  can  you  hope  to  see  any  benefit  result  from  the  cold  applications 
to  the  head  in  the  advanced  stages  of  the  disease.  I  need  scarcely  say 
that  the  application  of  cold  with  a  shock,  or  the  pouring  cold  water 
from  a  height  upon  the  head,  though  a  very  valuable  means  of  arousing 
a  child  from  the  state  of  coma  into  which  it  sinks  in  some  cases  of  in- 
tense cerebral  congestion,  is  wholly  inapplicable  in  the  coma  of  hydro- 
cephalus. The  functions  of  the  brain  are  here  not  merely  interrupted 
by  the  excess  of  blood  in  the  organ,  but  they  are  abolished  by  the  dis- 
organization of  its  tissue,  or  the  compression  of  its  substance  by  the 
effusion  of  fluid. 

In  the  management  of  children  attacked  by  hydrocephalus  you  must 
not  forget  that  for  the  most  part  they  are  of  feeble  constitution,  and 
that  they  will  not  bear  too  rigorous  a  diet.  Just  at  first,  indeed,  while 
the  febrile  symptoms  run  high,  and  the  bowels'  are  unrelieved,  or  the 
sickness  is  urgent,  the  less  the  patient  takes  the  better.  Afterwards, 
however,  it  is  desirable  that  he  should  be  supplied  with  as  much  light 
and  unstimulating  nutriment  as  he  will  take ;  such,  for  instance,  as  ar- 
row-root, or  veal  or  beef-tea,  either  of  which  will  often  remain  on  the 
stomach  when  most  other  articles  of  food  or  drink  would  be  rejected. 

In  the  treatment  of  many  diseases  you  see  physicians  destroy  the 
sense  of  pain  by  narcotics,  and  the  question  naturally  suggests  itself 
to  you  whether  you  may  not  sometimes  venture,  in  the  management  of 
hydrocephalus,  to  mitigate  by  their  means  your  patient's  sufferings. 
The  enquiry  is  one  not  very  easy  to  reply  to  satisfactorily.  I  think, 
however,  that  there  are  two  conditions  under  which  you  would  be  justi- 
fied in  trying  the  experiment  of  giving  them.  Sometimes  the  disease 
sets  in  with  great  excitement,  and  a  condition  closely  resembling  mania 
in  the  adult,  symptoms  which  may  have  been  ushered  in  by  convulsions. 
In  such  a  case,  although  the  heat  of  head  and  the  flush  of  the  face  may 
have  disappeared  after  free  depletion  and  the  copious  action  of  purga- 


DIET  IN   HYDROCEPHALUS — USE   OF   NARCOTICS — OF  BLISTERS.  81 

tive  medicine,  and  though  the  pulse  is  feeble  as  well  as  frequent,  yet  the 
excitement  may  be  scarcely  if  at  all  diminished.  Here  an  opiate  will 
sometimes  give  the  relief  which  nothing  else  will  procure  ;  your  patient 
will  fall  asleep,  and  wake  tranquillized  in  the  course  of  two  or  three 
hours.  In  other  cases,  which  did  not  set  in  thus  violently,  restlessness, 
talkativeness,  and  a  kind  of  half  delirious  consciousness  of  pain  in  the 
head,  become  very  distressing  as  the  disease  advances,  being  always 
aggravated  at  night,  so  that  your  patient's  condition  seems  one  of  con- 
stant suffering.  But  he  is  not  able  to  bear  any  more  active  treatment, 
and,  indeed,  you  have  already  emptied  your  quiver  of  such  weapons. 
Under  these  circumstances  I  have  sometimes  given  a  full  dose  of  mor- 
phia, and  have  continued  it  every  night  for  several  nights  together  with 
manifest  relief. 

Another  inquiry  that  you  may  put  is,  when  are  you,  to  employ  blisters  t 
Certainly  not  at  the  beginning  of  the  disease,  when  they  would  increase 
the  general  irritation,  and  do  more  harm  than  good.  At  a  later  period 
they  may  be  of  service,  when  the  excitement  is  about  to  yield  to  that 
stupor  which  usually  precedes  the  state  of  complete  coma.  They  should 
then  be  applied  to  the  nape  of  the  neck  or  to  the  vertex ;  and  I  am  dis- 
posed to  think  the  latter  the  better  place,  since,  when  applied  to  the 
nape  of  the  neck  they  often  become  displaced  by  that  boring  movement 
of  the  head  which  the  child  in  many  instances  keeps  up  unconsciously. 
It  is  well,  too,  to  remember  that  the  skin  in  hydrocephalus  is  very  inapt 
to  vesicate,  so  that  a  blister  will  require  to  be  kept  on  for  ten  or  twelve 
hours  ;  contrary  to  what  ought  to  be  your  usual  practice  with  children. 
Cases  enough  are  on  record  proving  the  utility  of  blisters  thus  applied, 
to  render  it  your  duty  not  to  neglect  this  means. 

Need  I  say  that  you  must  not  think  of  treating  a  case  of  hydroce- 
phalus throughout  just  in  the  same  way  as  you  did  at  its  commencement. 
There  is,  if  the  disease  do  not  run  a  very  rapid  course,  a  stage  of  weak- 
ness and  exhaustion,  often  associated  with  a  half  comatose  condition, 
though  sometimes  attended  with  a  considerable  degree  of  suffering, 
which  frequently  precedes  the  signs  of  approaching  death.  The  bowels 
are  now  sometimes  relaxed,  though  oftener  they  continue  constipated, 
because  the  nervous  energy  which  kept  up  the  peristaltic  movements  of 
the  intestines  is  worn  out.  The  powers  of  organic  as  well  as  those  of 
animal  life  are  palsied.  This  is  the  time  for  the  administration  of  quinine, 
for  the  employment  of  nutritious'broths  and  jellies,  and  even  of  wine. 

You  may  perhaps  be  disposed  to  ask  me  what  I  think  of  this  remedy 
or  the  other,  which  has  at  different  times  been  boasted  of,  as  having 
done  good  when  other  means  had  failed.  Now  you  must  not  infer  from 
my  silence  that  I  do  not  believe  that  other  medicines  besides  those 
which  I  have  spoken  of  have  been  of  service ;  but  to  attempt  to  can- 
vas the  respective  merits  of  each  would,  I  fear,  be  a  tedious  task,  and 
one  from  which  you  would  derive  but  little  profit. 

Besides,  may  I  remind  you  of  what  Sydenham  says,  "*  *  *  In  eo 
praecipue  stat  Medicina  Practica,  ut  genuinas  Indicationes  expiscari 
valeamus,  non  ut  remedia  excogitemus  quibus  illis  satisfieri  possit ;  quod 
qui  minus  observabant,  Empericos  armis  instruxere,  quibus  Medicorum 
opera  imitari  queant." 


82 


LECTURE   VII. 

Simple  Inflammation  of  the  brain — its  differences  from  hydrocephalus — occasional 
extreme  rapidity  of  its  course — cases  in  illustration — morbid  appearances — frequent 
connection  with  meningitis  of  the  cord — extreme  rarity  as  an  idiopathic  affection 
— treatment. 

Inflammation  of  the  Brain,  succeeding  to  Disease  of  the  Ear — digression  con- 
cerning otitis — its  symptoms — distinctions  between  it  and  inflammation  of  the 
brain — treatment — chronic  otorrhoea,  with  disease  of  the  temporal  bone — case. 

Phlebitis  of  the  Sinuses  of  the  Dura  Mater — circumstances  under  which  it  occurs 
— it  sometimes  succeeds  to  large  collections  of  pus  in  distant  organs — case  in 
illustration. 

We  have  been  engaged  at  our  last  two  meetings  with  the  study  of  one 
form  of  inflammation  of  the  brain  in  the  young  subject.  We  found  hy- 
drocephalus to  be  an  affection  almost  exclusively  confined  to  children 
whose  previous  health  had  been  indifferent,  who  had  shown  some  indi- 
cations of  phthisis,  or  in  whose  family  phthisical  disease  existed.  We 
observed  its  development  to  be  gradual,  its  progress  often  tardy,  and 
attended  with  irregular  remissions,  but  its  issue  almost  always  fatal. 
The  alterations  of  structure  discovered  after  death  were  seen  to  be 
slight  at  the  convexity  of  the  brain,  but  very  obvious  at  its  base, 
where,  in  addition  to  the  effects  of  inflammation,  the  membranes  often 
present  a  peculiar  granular  appearance.  The  fluid  contained  in  the 
ventricles  of  the  brain  is  almost  always  transparent,  and  tubercle  is 
discovered  in  some,  often  in  many  of  the  viscera. 

But  we  sometimes  meet  with  cases  in  which  inflammation  of  the  brain 
has  given  rise  to  changes  that  contrast  remarkably  with  those  which 
true  hydrocephalus  produces.  We  find  the  cerebral  membranes  intensely 
injected,  the  effusion  of  lymph  or  pus  abundant,  especially  about  the 
convex  surface  of  the  brain,  where  it  sometimes  forms  a  layer  concealing 
the  convolutions  from  view.  Moreover,  the  fluid  that  occupies  the  cavity 
of  the  arachnoid,  as  well  as  that  within  the  ventricles,  is  turbid  and 
mixed  with  lymph,  while  the  membranes  present  no  trace  of  that  granular 
appearance  so  remarkable  in  true  hydrocephalus,  and  the  various  organs 
of  the  body  are  free  from  tubercle. 

If  we  inquire  as  to  the  symptoms  by  which  this  disease  was  attended 
during  the  life-time  of  the  patient,  we  shall  most  likely  find  that  they 
present  fresh  reasons  for  distinguishing  between  it  and  hydrocephalus. 
We  shall  learn  that  the  attack  came  on  in  a  previously  healthy  child, 
that  it  was  either  ushered  in  by  convulsions,  or  that  they  soon  occurred, 
that  they  returned  often,  and  probably  that  they  continued  with  but 
little  intermission  until  death  took  place.  We  shall  be  told,  moreover, 
that  the  disease  set  in  with  violent  vomiting  and  intense  febrile  excite- 
ment ;  and  that  having  commenced  thus  severely,  it  advanced  rapidly, 
and  without  remission,  to  its  fatal  termination,  which  may  have  arrived 
in  the  course  of  a  few  hours,  and  is  seldom  delayed  beyond  the  first 
week. 


SIMPLE  INFLAMMATION   OF   THE  BRAIN.  83 

Some  cases  of  this  simple  encephalitis  are  recorded  by  Golis,  under 
the  name  of  Water-stroke :  I  will  select  one  of  them,  as  affording  a 
good  specimen  of  the  most  acute  form  of  the  disease.1 

"  A  little  girl,  14  months  old,  who  was  healthy  and  strong  and  fat,  was 
suddenly  seized  at  5  o'clock  in  the  morning,  after  a  restless  night,  with 
violent  fever  and  frightful  general  convulsions.  Medical  assistance  was 
at  once  attained,  and  in  less  than  thirty  minutes  from  the  commence- 
ment of  the  attack,  four  leeches  were  applied  behind  the  ears,  which 
drew  three  ounces  of  blood :  calomel  and  other  remedies  were  admi- 
nistered internally,  and  mustard  poultices  were  applied  to  the  soles  of 
the  feet.  These  measures  soon  alleviated  the  symptoms,  but  the  relief 
lasted  for  but  a  very  short  time;  the  fever  returned  as  intensely  as 
before,  convulsions  came  on  again,  attended  with  opisthotonos,  and  the 
child  became  comatose.  Hemiplegia  succeeded ;  the  pupils  became 
extremely  contracted :  complete  loss  of  vision,  and  spasmodic  twitching 
of  the  muscles  of  the  face  soon  followed,  and  thirteen  hours  after  the 
first  convulsive  seizure,  in  spite  of  most  appropriate  and  energetic 
treatment,  the  little  child  died. 

"  The  vessels  of  the  scalp  were  loaded  with  blood,  and  the  skull  was 
so  intensely  congested  as  to  appear  of  a  deep  blue  colour.  The  sinuses 
were  full  of  coagulated  blood  mixed  with  lymph,  and  all  the  vessels  of 
the  brain  and  its  membranes  were  enlarged  and  turgid  with  blood. 

"  A  large  quantity  of  coagulated  lymph  covered  the  convolutions  of 
the  brain  and  the  corpus  callosum  like  a  false  membrane,  and  furnished 
a  delicate  lining  to  the  lateral  ventricles,  whose  walls  were  softened 
and  in  part  broken  down.  The  ventricles  contained  about  three  ounces 
of  turbid  serum,  and  there  was  a  considerable  quantity  of  lymph  at  the 
base  of  the  brain." 

As  I  have  never  seen  an  instance  of  this  most  rapid  form  of  menin- 
gitis, I  will  draw  for  another  illustration  of  it  upon  that  valuable  store- 
house of  facts,  Dr.  Abercrombie's  work  on  Diseases  of  the  Brain.2 

"  A  child,  aged  2  years,  21st  May,  1826,  was  suddenly  seized  in  the 
morning  with  severe  and  long-continued  convulsion.  It  left  her  in  a 
dull  and  torpid  state,  in  which  she  did  not  seem  to  recognize  the  persons 
about  her.  She  had  lain  in  this  state  for  several  hours,  when  the  con- 
vulsion returned,  and  during  the  following  night  it  recurred  a  third  time, 
and  was  very  severe  and  of  long  continuance.  I  saw  her  on  the  morning 
of  the  23d,  and  while  I  was  sitting  by  her  she  was  again  attacked  with 
severe  and  long-continued  convulsion,  which  affected  every  part  of  the 
body,  the  face  and  the  eyes  in  particular  being  frightfully  distorted. 
The  countenance  was  pale,  and  expressive  of  exhaustion ;  the  pulse 
frequent.  Her  bowels  had  been  freely  opened  by  medicine  previously 
prescribed  by  Dr.  Beilby,  and  the  motions  were  dark  and  unhealthy. 
Farther  purging  was  employed,  with  topical  bleeding,  cold  applications 
to  the  head,  and  blistering.  After  this  attack  she  continued  free  from 
convulsion  till  the  afternoon  of  the  23d ;  in  the  interval  she  had  remained 
in  a  partially  comatose  state,  with  frequent  starting;  pulse  frequent, 

1  Praktische  Abhandlungen,  etc.  vol.  i.  Case  2. 

2  Case  10,  p.  52- 


84  SIMPLE   INFLAMMATION   OP   THE   BRAIN. 

but  feeble ;  pupils  rather  dilated  :  she  took  some  food.  In  the  afternoon 
of  the  23d  the  convulsion  returned  with  greater  severity ;  and  on  the 
24th  there  was  a  constant  succession  of  paroxysms  during  the  whole 
day,  with  sinking  of  the  vital  powers;  and  she  died  early  in  the 
evening. 

"On  removing  the  dura  mater,  the  surface  of  the  brain  appeared  in 
many  places  covered  by  a  deposition  of  adventitious  membrane  betwixt 
the  arachnoid  and  pia  mater.  It  was  chiefly  found  above  the  openings 
between  the  convolutions,  and  in  some  places  appeared  to  dip  a  little 
way  between  them.  The  arachnoid  membrane  when  detached  appeared 
to  be  healthy,  but  the  pia  mater  was  throughout  in  the  highest  state  of 
vascularity,  especially  between  the  convolutions ;  and  when  the  brain 
was  cut  vertically,  the  spaces  between  the  convolutions  were  most  strik- 
ingly marked  by  a  bright  line  of  vivid  redness,  produced  by  the  inflamed 
membrane.  There  was  no  effusion  in  the  ventricles,  and  no  other 
morbid  appearance." 

It  would  not  answer  any  useful  purpose  to  multiply  the  recital  of 
cases,  since  though  there  are  great  varieties  in  the  duration  of  the 
disease,  yet  its  general  features  are  the  same  in  almost  every  instance, 
and  will,  I  think,  readily  be  recognized  by  you  as  betokening  an  affec- 
tion very  different  from  ordinary  hydrocephalus. 

The  morbid  appearances  are  sometimes  found  to  vary  both  in  their 
degree  and  in  their  extent,  without  any  corresponding  difference  being 
observed  in  the  symptoms.  With  the  exception  of  its  course  being  more 
rapid,  Golis's  case  differed  but  little  from  that  recorded  by  Dr.  Aber- 
crombie.  I  believe  that  in  the  majority  of  instances  the  lining  of  the 
ventricles  is  affected ;  and  it  is  certainly  more  common  for  the  mem- 
branes at  the  base  of  the  brain  to  be  involved  in  the  disease,  than  for  it 
to  be  entirely  limited  to  those  at  the  convexity.  It  may  also  be  doubted 
whether  the  membranes  of  the  spinal  cord  are  not  also  affected  in 
the  greater  number  of  cases  ;  but  unfortunately  the  histories  of  but  few 
post-mortem  examinations  contain  complete  details  with  reference  to 
their  condition.  I  have  had  the  opportunity  of  examining  five  fatal 
cases  of  acute  meningitis  in  infants  or  children,  and  in  three  of  these 
there  was  not  only  abundant  deposit  of  lymph  on  the  surface  of  the 
convolutions,  but  it  was  effused  copiously  at  the  base  of  the  brain ;  the 
ventricles  contained  turbid  serum  intermixed  with  flakes  of  lymph  ;  and 
the  membranes  of  the  spinal  cord  were  inflamed,  and  coated  in  many 
parts  with  lymph  and  pus.  In  all  of  these  three  cases  the  children  were 
under  a  year  old,  and  the  disease  came  on  without  any  assignable  cause, 
as  it  did  also  in  the  case  of  another  little  boy,  aged  13  months.  In  that 
instance,  however,  no  lymph  was  effused  anywhere ;  the  ventricles  con- 
tained only  a  small  quantity  of  transparent  fluid,  and  the  most  remark- 
able appearance  consisted  in  an  intense  injection  of  the  pia  mater  of  the 
convexity  and  of  the  surface  of  the  convolutions  for  about  two  lines  in 
depth,  the  cerebral  substance  in  that  situation  being  softened,  so  that 
portions  of  it  were  removed  when  the  pia  mater  was  stripped  off.  In 
another  instance,  where  all  the  symptoms  of  encephalitis  succeeded  to 
an  injury  of  the  neck  and  head,  the  membranes  at  the  convexity  of  the 
brain,  and  also  the  choroid  plexuses  and  the  velum  interpositum,  were 


SIMPLE  INFLAMMATION   OF   THE   BRAIN.  85 

intensely  red;  there  was  much  effusion  in  the  sub-arachnoid  tissue ;  not 
much  in  the  lateral  ventricles,  though  their  lining  was  considerably 
thickened.  The  substance  of  the  brain  was  injected  and  much  softer 
than  natural,  especially  towards  the  centre  of  the  organ  and  at  its  left 
side.  In  both  of  these  cases  the  membranes  at  the  base  of  the  brain 
were  perfectly  healthy,  but  the  spinal  cord  was  not  examined. 

I  have  seen  two  other  cases  in  which  I  believe  that  inflammation 
existed  of  the  meninges  both  of  the  brain  and  spinal  cord,  but  in  which 
I  had  no  opportunity  of  making  an  examination  after  death.  These  seven 
cases  constitute  the  whole  of  my  experience  in  this  formidable  disease. 

Acute  inflammation  of  the  brain  or  its  membranes  is  fortunately  of 
very  rare  occurrence  in  childhood,  except  as  the  result  of  fracture  of 
the  skull,  or  of  injury  to  the  head  or  neck.  Exposure  to  the  heat  of  the 
sun  has  been  known  to  induce  it;  sometimes  it  occurs  in  children  who 
are  apparently  recovering  from  scarlatina ;  and  at  other  times  it  occurs 
without  our  being  able  to  trace  it  to  any  definite  cause. 

In  the  treatment  of  this  affection,  our  remedies  must  be,  in  the  main, 
the  same  as  we  should  employ  to  combat  the  acute  inflammation  of  any 
other  vital  organ.  Bleeding,  purgatives,  mercurials,  and  the  application 
of  cold,  are  the  grand  means  on  which  we  must  rely ;  and  these  must 
be  used  with  an  unsparing  hand  if  we  would  have  any  chance  of  saving 
our  patient.  Our  prospect  of  success,  however,  depends  almost  entirely 
upon  our  seeing  the  patient  at  the  very  outset.  The  case  which  I  quoted 
from  Golis  shewed  you  what  extensive  mischief  may  occur  in  thirteen 
hours,  and  instances  are  on  record  in  which  a  greater  amount  of  injury 
has  been  discovered  after  a  still  shorter  train  of  symptoms.  Even  in 
those  cases  which  do  not  run  this  extremely  rapid  course,  and  in  which 
the  mischief  found  after  death  is  not  so  considerable,  there  is  little  less 
need  for  speedy  as  well  as  active  interference,  for  if  life  be  prolonged 
for  a  day  or  two  without  the  disease  being  overcome,  the  patient  often 
sinks  into  an  exhausted,  or,  as  the  French  call  it,  an  ataxic  condition, 
in  which  active  treatment  can  no  longer  be  ventured  on. 

Formidable  though  these  cases  are,  yet  if  seen  early,  and  treated 
actively,  they  may  be  regarded  more  hopefully  than  those  in  which  the 
brain  and  its  membranes  become  inflamed  in  consequence  of  the  exten- 
sion to  them  of  disease  beginning  without  the  skull.  You  will  occa- 
sionally see  instances  of  this  occurrence  in  children  who  have  suffered 
from  scrofulous  disease  of  the  cervical  vertebrae,  when  a  life  of  suffer- 
ing is  terminated  by  a  most  painful  death ;  or  inflammation  of  the 
brain,  proving  very  quickly  fatal,  may  come  on  in  a  child  who  has  long 
had  discharge  from  the  ear,  with  occasional  attacks  of  ear-ache.  Vague 
threatenings  of  mischief  in  the  head  may  perhaps  have  existed  for 
some  time,  just  sufficient  to  excite  your  apprehension,  but  not  so  serious 
or  so  definite  as  to  call  for  decided  interference  ;  and  yet,  when  death 
takes  place,  you  will  find  it  almost  impossible  to  reconcile  the  existence 
of  lesions  so  extensive  and  of  such  long  standing  as  a  post-mortem 
examination  discovers,  with  the  long-continued  absence  of  definite 
cerebral  symptoms. 

In  Dr.  Abercrombie's  work  on  diseases  of  the  Brain,1  an  account  is 

1  Page  37 ;  quoted  from  Mr.  Parkinson,  in  London  Med.  E-epository,  March  1817. 


86  BEGINNING  WITHOUT  THE   SKULL. 

given  of  a  boy,  aged  14  years,  who  had  been  affected  for  two  months 
with  headache  and  discharge  of  matter  from  the  right  ear.  A  week 
before  his  death  the  pain  increased,  and  was  accompanied  by  great 
debility,  giddiness,  and  some  vomiting.  He  continued  in  this  state, 
without  stupor  or  any  other  remarkable  symptom,  until  the  day  of  his 
death,  when  he  was  suddenly  seized  with  convulsions,  and  died.  An 
abscess  was  found  in  the  middle  lobe  of  the  right  hemisphere  of  the 
brain,  and  another  in  the  cerebellum,  and  there  was  extensive  caries  of 
the  pars  petrosa,  with  effusion  of  three  ounces  of  fluid  in  the  ventricles. 

I  have  quoted  this  case  in  order  to  impress  upon  your  minds  that 
every,  even  the  slightest,  indication  of  cerebral  disturbance  is  to  be 
looked  on  with  the  greatest  anxiety  in  children  who  have  suffered  from 
chronic  otorrhoea.  Your  solicitude  must  be  redoubled  if  the  discharge 
from  the  meatus  had  ever  been  attended  with  the  formation  of  abscesses 
at  the  back  of  the  ear,  or  burrowing  between  the  cartilage  and  the 
bone,  since  they  would  render  it  extremely  probable  that  caries  of  the 
bone  had  existed,  and  that  the  membranes  of  the  brain  had  been 
reached  by  the  advance  of  the  disease. 

Inflammation  of  the  brain  occasionally  supervenes  on  disease  of  the 
internal  ear,  even  though  there  have  been  no  actual  exposure  of  the  dura 
mater  by  destruction  of  the  bone,  and  though  attacks  of  otitis  have  not 
been  of  frequent  occurrence.  Attacks  of  otitis,  indeed,  are  of  impor- 
tance, not  merely  on  account  of  the  occasional  supervention  upon  them 
,of  inflammation  of  the  brain,  but  also  on  account  of  the  severe  suffer- 
ing by  which  they  are  always  attended.  In  many  instances,  too, 
needless  alarm  may  be  excited  by  the  symptoms  of  inflammation  of  the 
ear  being  supposed  to  betoken  that  the  brain  itself  is  the  seat  of  the 
mischief ;  and  hence  it  is  very  desirable  to  become  familiar  with  the 
diagnostic  marks  that  distinguish  the  less  from  the  more  dangerous 
affection. 

Inflammation  of  the  internal  ear  is  most  frequent  before  the  com- 
pletion of  the  first  dentition,  and  is  by  no  means  rare  in  young  children 
who  are  perfectly  unable  to  point  out  the  seat  of  their  sufferings.  The 
attack  sometimes  comes  on  quite  suddenly,  but  usually  the  child  is 
fretful  and  languid  for  a  period  varying  from  a  few  hours  to  one  or  two 
days  before  acute  pain  is  experienced.  In  this  premonitory  stage, 
however,  it  will  often  cry,  if  tossed  or  moved  briskly,  noise  seems 
unpleasant  to  it,  and  it  does  not  care  to  be  played  with  ;  while  children 
who  are  still  at  the  breast  shew  a  disinclination  to  suck,  though  they 
will  take  food  from  a  spoon.  The  infant  seeks  to  rest  its  head  on  its 
mother's  shoulder,  or,  if  lying  in  its  cot,  moves  its  head  uneasily  from 
side  to  side,  and  then  buries  its  face  in  the  pillow.  If  you  watch 
closely,  you  will  see  that  it  is  always  the  same  side  of  the  head  which 
it  seeks  to  bury  in  the  pillow,  or  to  rest  on  its  nurse's  arm,  and  that  no 
other  position  seems  to  give  any  ease  except  this  one,  which,  after 
much  restlessness,  the  child  will  take  up,  and  to  which,  if  disturbed,  it 
will  always  return.  The  gentle  support  to  the  ear  seems  to  soothe  the 
little  patient ;  it  cries  itself  to  sleep,  but  after  a  short  doze  some  fresh 
twinge  of  pain  arouses  it,  or  some  accidental  movement  disturbs  it,  and 
it  awakes  crying  aloud,  and  refusing  to  be  pacified,  and  may  continue 


INFLAMMATION   OF  THE  INTERNAL  EAR.  87 

so  for  hours  together.  Sometimes  the  external  ear  is  red,  and  the  hand 
is  often  applied  to  the  affected  side  of  the  head ;  but  neither  of  these 
symptoms  is  constant.  The  intensity  of  the  pain  seldom  lasts  for  more 
than  a  few  hours,  when  a  copious  discharge  of  offensive  pus  takes 
place  from  the  ear,  and  the  child  is  well.  Sometimes,  indeed,  this 
complete  cure  does  not  take  place,  but  the  ear-ache  abates,  or  alto- 
gether ceases,  for  a  day  or  two,  and  then  returns ;  no  discharge,  or 
but  a  very  scanty  discharge  taking  place,  while  for  weeks  together  the 
child  has  but  few  intervals  of  perfect  ease.  In  infants  ear-ache  seldom 
follows  this  chronic  course,  though  I  have  occasionally  seen  it  do  so  in 
older  children. 

In  children  who  are  too  young  to  express  their  sufferings  by  words, 
the  violence  of  their  cries,  coupled  with  the  absence  of  all  indications 
of  disease  in  the  chest  or  abdomen,  naturally  lead  to  the  suspicion  of 
something  being  wrong  in  the  head.  There  are  three  circumstances, 
however,  which  may  satisfy  you  that  the  case  is  not  one  of  ordinary 
hydrocephalus ;  the  child  does  not  vomit,  the  bowels  are  not  constipated, 
and  there  is  but  little  febrile  disturbance.  The  loud  and  passionate 
cry,  the  dread  of  movement,  and  the  evident  relief  afforded  by  resting 
one  side  of  the  head,  are  evidences  of  the  ear  being  affected ;  while 
in  many  instances  the  movement  of  the  hand  to  the  head,  and  the  red- 
ness of  the  external  ear,  with  the  swelling  of  the  meatus,  concur  to 
make  the  diagnosis  easy.  Sometimes,  when  in  doubt,  you  will  be  able 
to  satisfy  yourself  that  the  cause  of  suffering  is  in  the  ear,  by  pressing 
the  cartilages  of  the  organ  slightly  inwards,  which  will  produce  very 
evident  pain  on  the  affected  side,  while,  if  practised  on  the  other  side, 
it  will  not  occasion  any  suffering. 

The  treatment  of  this  painful  affection  is  very  simple.  In  many 
instances  the  suffering  is  greatly  relieved  by  warm  fomentations,  or 
by  applying  to  the  ear  a  poultice  of  hot  bran  or  camomile-flowers.  A 
little  oil,  to  which  some  laudanum  has  been  added,  may  be  dropped 
into  the  ear,  and  repeated  from  time  to  time ;  while  if  the  pain  be 
extremely  severe,  or  have  continued  for  several  hours,  it  may  be  wise 
to  apply  a  few  leeches  to  the  mastoid  process.  If  the  ear-ache  return 
frequently,  a  small  blister  should  be  applied  behind  the  ear,  or  slight 
vesication  may  be  produced  by  means  of  the  acetum  cantharidis. 

The  possible  supervention  of  inflammation  of  the  brain  must  of  course 
be  borne  in  mind,  and  any  indication  of  its  approach  must  be  imme- 
diately combated;  but  fortunately  this  occurs  less  frequently  as  a 
complication  of  otitis  than  as  a  sequela  of  long-continued  purulent 
discharge  from  the  ear,  which  has  probably  been  attended  with  constant 
though  not  very  severe  pain  in  the  head.  A  little  boy,  four  years  old, 
has  for  some  time  been  under  my  care,  who  has  suffered  for  the  last 
eighteen  months  from  purulent  discharge  of  a  very  offensive  character 
from  both  ears.  After  this  discharge  had  continued  for  six  months,  an 
abscess  formed  behind  the  left  ear,  which,  on  being  opened,  gave  issue 
to  ^ij.  of  very  foetid  pus.  A  month  afterwards  a  large  portion  of  the 
mastoid  process  of  the  left  temporal  bone  was  exfoliated,  and  for 
several  weeks  after  this  occurrence  the  left  side  of  the  face  was  fre- 
quently thrown  into  a  state  of  twitching  movement,  which  showed  that 


88  TREATMENT   OF   OTITIS. 

some  of  the  branches  of  the  portio  dura  had  been  Involved  in  the  disease. 
This  symptom  has  disappeared  for  the  past  nine  months,  but  the  dis- 
charge continues  as  foetid  as  ever,  though  now  much  more  profuse  from 
the  right  than  from  the  left  ear ;  and  the  abscess  has  long  ceased  to 
discharge,  though  a  fistulous  opening  still  continues  which  leads  down 
to  the  diseased  bone.  This  little  boy  is  in  almost  constant  suffering 
from  headache.  Sometimes  the  pain  is  very  severe,  and  quite  prevents 
his  sleeping,  and  then  it  will  abate  for  several  days  or  weeks  without 
any  evident  cause.  There  can,  however,  be  little  doubt  but  that  sooner 
or  later  an  acute  attack  of  inflammation  of  the  membranes  of  the  brain 
will  come  on,  and  prove  quickly  fatal. 

In  those  cases  where  offensive  puriform  discharge  from  the  ear  has 
been  of  long  continuance,  and  the  matter  is  sometimes  tinged  or  streaked 
with  blood,  astringent  injections  must  be  used  only  with  the  greatest 
care,  while  their  employment  is  not  at  all  advisable  if  exfoliation  of 
bone  have  taken  place,  since  in  such  a  case  not  only  is  the  internal  ear 
disorganized,  but  the  dura  mater  has  very  probably  become  exposed. 
Attention  to  cleanliness,  by  frequently  syringing  out  the  ear  with  warm 
water,  or  with  a  solution  of  gr.  j.  or  gr.  ij.  of  the  acetate  of  lead  in  an 
ounce  of  water,  constitute  all  the  topical  treatment  on  which  it  would 
be  safe  to  venture,  while  the  most  sedulous  attention  must  be  paid  to 
the  general  health  of  the  patient. 

It  still  remains  for  me  to  notice  one  singular  form  of  cerebral  disease, 
which,  though  not  confined  to  children,  is  seen  much  oftener  among 
them  than  among  adults  ;  namely,  phlebitis  of  the  sinuses  of  the  dura 
mater.  In  grown  persons  it  usually  succeeds  to  some  injury  of  the 
head,  but  in  the  child  it  has  generally  been  observed  as  a  consequence 
of  long-continued  purulent  otorrhoea,  combined  with  disease  of  the 
temporal  bone,  or  it  has  been  connected  with  disease  of  the  frontal 
sinuses,  or  has  followed  an  abscess  of  the  scalp.  In  one  or  two 
instances,  also,  it  has  seemed  to  be  excited  by  the  presence  of  large 
collections  of  pus  in  distant  parts  of  the  body.  JVL  Tonnele,  who  has 
written  a  very  valuable  paper  on  inflammation  of  the  sinuses  of  the 
dura  mater  in  children,1  records  one  instance  in  which  it  coincided  with 
a  pleuritic  effusion ;  and  a  somewhat  similar  case  has  come  under  my 
own  notice,  which  I  will  relate,  partly  on  account  of  its  rarity,  partly 
because  it  illustrates  exceedingly  well  the  morbid  appearances  observed 
in  cases  of  this  description. 

A  healthy  little  girl  was  attacked  by  scarlatina  when  eight  months 
old.  The  attack  was  not  severe,  but,  after  it  had  passed  away,  she  did 
not  regain  her  previous  health,  but  continued  restless  and  feverish  ;  she 
was  sometimes  sick,  and  her  eyelids  were  often  slightly  swollen.  A 
fortnight  after  the  rash  appeared,  she  had  one  or  two  violent  convulsive 
seizures,  but  they  ceased  after  her  gums  were  lanced,  and  did  not  appear 
to  be  in  any  way  connected  with  her  subsequent  illness.  She  continued 
out  of  health  untill  she  was  10J  months  old,  when  her  mother  noticed, 
in  addition  to  the  puffiness  of  the  eyelids,  a  swelling  of  the  legs  and 
abdomen,  for  which  she  came  under  my  care  when  eleven  months  old. 

1  Journal  ITebdomadaire,  vol.  y.  p.  337.     1825. 


INFLAMMATION   OP   THE   SINUSES   OP  THE  DURA  MATER.  89 

The  legs  were  then  very  ©edematous,  and  fluctuation  was  distinctly  felt 
through  the  parietes  of  the  abdomen,  the  urine  being  scanty  and  high 
coloured.  In  the  course  of  about  three  weeks  her  condition  had 
improved  considerably,  the  urine  having  increased  much,  the  anasarca 
having  greatly  diminished,  and  the  abdomen  being  1J  inch  less  in  cir- 
cumference. A  fit  of  convulsions  now  came  on  without  any  apparent 
cause,  but  no  other  symptoms  of  cerebral  mischief  followed  it,  and  the 
convulsion  did  not  return.  After  the  lapse  of  another  week  a  discharge 
of  sero-purulent  fluid  took  place  from  the  umbilicus,  and  continued  for 
several  days  in  quantities  of  from  a  quarter  to  half  a  pint  daily.  This 
discharge  was  attended  with  an  improvement  rather  than  a  deterioration 
in  the  child's  health ;  but  after  it  had  continued  for  eleven  days,  fever 
and  dyspnoea  suddenly  came  on,  with  dulness  on  percussion  over  the 
right  side  of  the  chest,  and  absence  of  respiratory  murmur  in  that 
situation.  The  discharge  ceased  for  a  week  during  the  urgency  of  the 
thoracic  symptoms,  but  then  reappeared,  though  scantily.  The  child 
now  grew  thinner  and  weaker,  and  sank  into  a  state  of  hectic.  No  new 
symptom  came  on  till  she  was  suddenly  seized  with  extreme  faintness, 
amounting  to  almost  perfect  syncope.  She  rallied,  however,  under  the 
use  of  stimulants,  but  forty-eight  hours  afterwards  the  faintness 
returned,  and  terminated  in  death,  without  any  convulsion  having  pre- 
ceded it,  just  five  months  and  a  half  after  the  attack  of  scarlatina,  and 
two  months  after  she  came  under  my  care. 

On  an  examination  of  the  body  after  death,  pleurisy  of  the  right  side 
was  discovered,  with  about  ^vj.  of  pus  in  the  right  pleura,  and  perito- 
nitis, with  Oiij.  of  pus  in  the  abdomen ;  the  passage  being  still  traceable 
through  which  the  fluid  had  escaped  at  the  umbilicus. 

The  dura  mater  adhered  firmly  to  the  skull,  along  the  posterior  half 
of  the  longitudinal  sinus,  at  the  torcular  Herophili,  and  along  the  left 
lateral  sinus  ;  but  elsewhere  it  was  easily  detached  from  the  cranium. 

The  sinuses  on  the  right  side  were  healthy,  but  the  blood  within  them 
was  almost  entirely  coagulated.  The  posterior  half  of  the  longitudinal 
sinus,  the  torcular,  the  left  lateral  and  left  occipital  sinuses,  were  blocked 
up  with  fibrinous  coagulum,  precisely  such  as  one  sees  in  inflamed  veins, 
and  the  clot  extended  into  the  internal  jugular  vein.  The  coats  of  the 
longitudinal  and  of  the  inner  half  of  the  lateral  sinus  were  much 
thickened,  and  their  lining  membrane  had  lost  its  polish,  was  uneven, 
and  presented  a  dirty  appearance. 

There  was  some  congestion  of  the  arachnoid,  a  considerable  quantity 
of  fluid  in  the  ventricles,  and  sections  of  the  brain  presented  more 
bloody  points  than  natural,  especially  on  the  left  side.  The  base  of 
the  brain  was  perfectly  healthy  on  the  right  side,  but  there  was  great 
venous  congestion  beneath  the  middle  lobe  of  the  left  hemisphere,  and 
the  cerebral  veins  in  that  situation  were  distended  with  coagulum,  and 
their  coats  were  thickened.  Towards  the  anterior  part  of  the  left 
middle  lobe  were  four  apoplectic  effusions,  in  all  of  which  the  blood 
retained  its  natural  colour.  Each  of  these  effusions  was  connected 
with  an  obstructed  and  distended  vein.  The  largest  clot  extended 
an  inch  into  the  substance  of  the  brain ;  the  others  were  of  smaller 
extent. 


90  INFLAMMATION   OF   THE   SINUSES   OF   THE   DURA   MATER. 

I  cannot  speak  to  you  of  any  symptom  as  pathognomonic  of  this 
occurrence ;  it  usually  comes  on,  as  in  this  instance,  in  much  debili- 
tated children,  and  though  it  generally  follows  some  injury  or  disease 
in  the  neighbourhood  of  the  brain,  you  will  bear  in  mind  the  possibility 
of  its  occurrence  whenever  large  collections  of  pus  exist  in  any  part, 
and  would  draw  a  very  favourable  prognosis  in  the  event  of  head 
symptoms  coming  on  under  such  circumstances. 


LECTUEE    VIII 


Chronic  Hydrocephalus — Various  conditions  under  which  fluid  collects  in  the  skull 
— divided  into  the.texternal  and  the  internal — symptoms  of  both  nearly  identical — 
changes  in  form  and  size  of  the  head — and  their  mode  of  production — course  of  the 
disease — termination  almost  always  fatal. 

Internal  Hydrocephalus — important  questions  involved  in  its  pathology — frequent 
connection  with  malformation  of  brain — but  also  follows  inflammation  of  lining  of 
ventricles — description  of  post-mortem  appearances — case  illustrative  of  its  connec- 
tion with  inflammation — process  of  cure  usually  mere  arrest  of  disease. 

External'  Hydrocephalus — circumstances  under  which  it  exists — its  relation  to 
haemorrhage  into  the  arachnoid.  Treatment  of  both  forms  of  the  disease — Import- 
ance, but  difficulty,  of  distinguishing  curable  and  incurable  cases — Golis's  plan 
— Compression — Puncture — Cases  suited  for  each  mode  of  treatment. 

We  have  now  completed  our  examination  of  the  acute  inflammatory 
affections  of  the  brain,  and  with  them  we  may  consider  that  we  have 
dismissed  the  most  important  class  of  diseases  of  that  organ.  Before 
we  pass,  however,  to  those  in  the  production  of  which  inflammation 
bears  no  part,  we  must  study  one  malady  which  forms  a  kind  of  con- 
necting link  between  the  two. 

Chronic  Hydrocephalus,  or  Dropsy  of  the  Brain,  is  a  morbid  condition 
met  with  in  children  at  various  ages,  and  coming  on  under  a  great 
variety  of  circumstances.  Sometimes  it  is  congenital,  and  is  then  often, 
though  by  no  means  invariably,  associated  with  malformation  of  the 
brain.  In  subsequent  childhood,  an  excess  of  blood  in  the  brain,  or  its 
deficiency,  or  the  existence  of  some  impediment  to  the  circulation 
through  the  organ,  are  conditions  all  of  which  have  been  found  to  give 
rise  to  the  effusion  of  fluid  into  the  cavities  of  the  brain,  or  upon  its 
surface.  Instances  of  chronic  hydrocephalus  are  on  record,  which  have 
succeeded  to  haemorrhage  into  the  sac  of  the  arachnoid ;  others,  that 
have  been  connected  with  wasting  of  the  brain,  in  consequence  of  the 
supply  of  blood  being  inadequate  to  its  due  nutrition,  or  in  which  oblit- 
eration of  the  sinuses  by  disease,  or  the  pressure  of  a  morbid  growth 
upon  some  of  the  vessels  of  the  brain,  has  interfered  with  the  due  per- 
formance of  the  cerebral  circulation.  In  many  cases,  however,  I  believe 
as  do  MM.  Rokitansky  and  Vrolik,1  that  the  disease  is  not  a  mere 
passive  dropsy,  nqr  simply  a  consequence  of  arrested  cerebral  develope- 

1  Rokitansky,  Pathologische  Anatomie,  vol.  ii.  p.  754 ;  Vrolik,  Handboek  der  Ziekte- 
dundige  Ontleedkunde,  Amsterdam,  1840,  8vo.  p.  514-537. 


SYMPTOMS  OP  CHRONIC   HYDROCEPHALUS.  91 

merit,  but  that  it  is  the  result  of  a  slow  kind  of  inflammation  of  the 
arachnoid,  especially  of  that  lining  the  ventricles,  which  may  have 
existed  during  foetal  life,  or  may  not  have  attacked  the  child  until  after 
its  birth. 

According  to  the  situation  in  which  the  fluid  collects,  a  division  has 
been  made  of  chronic  hydrocephalus  into  the  external  and  the  internal ; 
the  former  term  being  applied  to  cases  in  which  the  fluid  collects  in  the 
sac  of  the  arachnoid ;  the  latter,  to  those  in  which  it  accumulates  in  the 
ventricles  of  the  brain.  The  two  conditions  sometimes  coexist,  but 
generally  they  are  independent  of  each  other ;  the  internal  hydroce- 
phalus being  the  more  frequent  and  the  more  important.  To  it,  there- 
fore, we  will  first  direct  our  attention,  premising,  however,  that  the 
symptoms  of  the  two  varieties  are  so  nearly  identical,  that  internal 
hydrocephalus  has  often  been  supposed  to  exist  in  cases  where  an 
examination  after  death  has  ascertained  that  the  fluid  was  in  reality 
situated  external  to  the  brain. 

The  early  symptoms  of  the  disease  vary.  When  it  is  congenital, 
indications  of  cerebral  disturbance  are  generally  apparent  from  the 
infant's  birth.  These  are  sometimes  serious — such,  for  instance,  as 
convulsions,  recurring  almost  daily;  at  other  times  they  are  compara- 
tively slight,  and  consist  in  nothing  more  than  strabismus,  or  a  strange 
rolling  of  the  eyes,  unattended  by  any  very  definite  sign  of  affection  of 
the  brain.  The  size  of  the  head  generally  attracts  attention  before 
long,  and  causes  importance  to  be  attached  to  symptoms  which  otherwise 
might  have  given  rise  to  but  little  anxiety.  In  some  instances,  however, 
the  increased  size  of  the  head  is  not  very  obvious  until  the  child  is  a  few 
weeks  old,  although  well-marked  symptoms  of  mischief  in  the  brain 
existed  from  its  birth.  Enlargement  of  the  head,  indeed,  is  by  no  means 
invariably  the  first  indication  of  chronic  hydrocephalus.  In  12  out  of 
45  cases,  fits,  returning  frequently,  had  existed  for  some  weeks  before 
the  head  was  observed  to  increase  in  size ;  in  6,  the  enlargement  of  the 
head  succeeded  to  an  attack  resembling  acute  hydrocephalus ;  and  in  4 
other  instances,  it  had  been  preceded  by  some  well-marked  indication 
of  cerebral  disturbance.  In  the  remaining  23  cases,  no  distinct  cerebral 
symptom  preceded  the  enlargement  of  the  head ;  but  in  almost  every 
instance  the  child's  health  had  been  noticed  to  be  failing  for  some  time, 
although  the  cause  of  its  illness  was  not  apparent. 

In  whatever  way  the  disease  begins,  impairment  of  the  process  of 
nutrition  is  sure  to  be  one  among  its  earliest  symptoms.  The  child  may 
suck  well,  and,  indeed,  may  seem  eager  for  food,  but  it  loses  both  flesh 
and  strength ;  and  often,  although  the  head  has  not  yet  attained  any 
disproportionate  size,  the  child  is  unable  to  support  it,  either  losing  the 
power  it  had  once  possessed,  or  never  attaining  that  which,  with  its 
increasing  age,  it  ought  to  acquire.  The  bowels  are  usually,  though  not 
invariably,  constipated.  Sometimes  diarrhoea  comes  on  for  a  day  or 
two ;  but,  under  either  condition,  the  evacuations  are  almost  always  of 
an  unhealthy  character.  Thus  far,  indeed,  there  is  but  little  to  dis- 
tinguish the  case  from  any  other  in  which  a  young  infant  is  imperfectly 
nourished ;  but  even  though  no  well-marked  cerebral  symptom  be  present, 
occasional  attacks  of  heat  of  the  head  will  be  observed,  attended  with 


92  CHANGES   IN   THE   FORM   OP   THE   SKULL. 

pulsation  or  tension  of  the  anterior  fontanelle,  while  crying  and  restless- 
ness often  alternate  with  a  drowsy  condition,  though  the  child  almost 
always  sleeps  ill  at  night.  In  many  instances,  too,  the  open  condition  of 
the  fontanelles  and  sutures  excites  attention  long  before  any  enlargement 
of  the  head  becomes  perceptible. 

By  and  by,  however,  the  increased  size  of  the  head  grows  very 
manifest,  and  the  child's  physiogonomy  soon  assumes  the  distinguishing 
features  of  chronic  hydrocephalus.  As  the  disease  advances  the  unos- 
sified  sutures  become  wider,  the  fontanelles  increase  in  size,  their  angles 
extend  far  into  the  sutures  in  "which  they  terminate,  while  the  fluid, 
pressing  equally  in  all  directions,  tends  to  impart  a  globular  shape  to 
the  receptacle  in  which  it  is  contained.  Some  of  the  casts  upon  the 
table  afford  striking  illustrations  of  this  change  in  the  form  of  the  cra- 
nium, which  would  be  still  more  remarkable  were  it  not  for  the  very 
unequal  resistance  of  different  parts  of  its  parietes.  The  bones  at  the 
vertex  of  the  skull  are  much  less  firmly  fixed  than  the  others,  and 
ossification  is  nowhere  so  tardy  as  at  the  anterior  fontanelle,  and  along 
the  inner  edges  of  the  parietal  bones.  Hence  it  results  that  the  great 
increase  in  the  size  of  the  head  is  effected  by  enlargement  of  the  anterior 
fontanelle,  and  by  widening  of  the  sagittal  suture.  The  os  frontis 
consequently  becomes  pushed  forwards,  the  parietal  bones  are  driven 
backwards  and  outwards,  and  the  occipital  bone  downwards  and  back- 
wards. The  displacement  of  the  bones  is  very  obvious  in  this  hydro- 
cephalic skull,  but  it  is  still  more  striking  in  the  two  engravings  which 
I  here  show  you.1  You  notice  the  great  prominence  of  the  forehead, 
and  the  alteration  in  the  position  of  the  parietal  bones,  which  are  driven 
backwards  as  well  as  outwards,  so  that  the  natural  relations  of  their 
protuberances  are  altogether  changed ;  while  in  this  remarkable  case  of 
a  man  named  Cardinal,  who,  though  hydrocephalic  from  his  infancy, 
lived  to  the  age  of  29  years,  the  occipital  bone  lies  almost  completely 
in  a  horizontal  position.  You  will  observe,  too,  another  remarkable 
alteration  produced  by  the  yielding  of  the  orbitar  plates  of  the  frontal 
bone,  which  are  driven  by  the  accumulating  fluid  from  a  horizontal  into 
an  oblique  direction.  Sometimes,  indeed,  they  become  nearly  perpen- 
dicular, when  by  contracting  the  orbits,  they  give  to  the  eyeballs  that 
unnatural  prominence,  and  that  peculiar  downward  direction,  which 
constitute  one  of  the  most  remarkable  features  in  cases  of  chronic 
hydrocephalus. 

Few  objects  are  more  pitiable  than  a  little  child  who  is  the  subject  of 
far  advanced  chronic  hydrocephalus.  While  the  skin  hangs  in  wrinkles 
on  its  attenuated  limbs,  the  enlarged  head  appears  full,  almost  to 
bursting,  owing  to  the  stretching  of  the  scalp ;  and  the  scanty  growth 
of  hair  does  not  at  all  conceal  the  distended  veins  that  run  over  its 
whole  surface.  The  size  of  the  skull,  too,  appears  greater  than  it  really 
is,  since  the  face  not  only  does  not  partake  of  the  enlargement,  but 
retains  its  infantile  dimensions  much  longer  than  natural.  The  eyes 
are  so  displaced  by  the  altered  direction  of  the  orbitar  plates,  that  the 

1  Baillie's  Morbid  Anatomy,  fasc.  x.  plate  iii.  fig.  1,  and  the  drawing  of  Cardinal's 
skull,  in  13right's  Reports,  vol.  ii.  part  2,  plate  xxxv. 


COURSE   AND   TERMINATION   OF   THE   DISEASE.  93 

white  sclerotica  projects  below  the  upper  lid,  and  the  iris  is  more  than 
half  hidden  beneath  the  lower.  Often,  too,  there  is  a  considerable 
degree  of  convergent  strabismus,  or  a  constant  rolling  movement  of  the 
eyeball,  which  the  child  is  unable  to  control ;  or  the  pupil  is  dilated, 
and  quite  insensible  to  light. 

The  symptoms  of  cerebral  disturbance  that  attend  the  advance  of  the 
disease  differ  much  in  severity.  Sometimes  there  is  little  besides  a  state 
of  uneasiness  and  restlessness,  aggravated  at  intervals  when  the  head 
grows  hot  and  the  fontanelle  becomes  tense.  In  other  cases  convulsions 
occur  very  frequently,  being  induced  by  extremely  slight  causes,  or 
coming  on  without  any.  In  several  instances  I  have  observed  spasmodic 
attacks  of  difficult  breathing,  attended  with  a  crowing  sound  in  inspira- 
tion, and  those  symptoms  which  constitute  spasmodic  croup,  seizures  of 
which  sometimes  come  on  even  before  there  is  much  enlargement  of  the 
head.  But,  whether  the  cerebral  symptoms  are  slight  or  severe,  almost 
every  case  of  chronic  hydrocephalus  has  pauses  in  its  course,  during 
which  the  child  seems  to  enjoy  comparative  immunity  from  suffering, 
and  gains  flesh,  while  its  head  ceases  for  a  time  to  enlarge.  Nothing, 
however,  can  be  more  variable  than  the  frequency  of  these  pauses,  or 
their  duration. 

Though  almost  every  case  of  chronic  hydrocephalus  is  fatal,  yet  death 
takes  place  in  very  different  ways.  Children  who  are  the  subjects  of 
the  disease  are  almost  always  very  weakly :  hence,  they  often  give  way 
under  the  first  serious  illness  that  attacks  them,  and  are  carried  off  by 
maladies  totally  unconnected  with  their  head  affection ;  while  many 
others  sink  into  that  state  of  atrophy  by  which  the  disease  of  the  brain 
is  often  accompanied,  and  die  exhausted.  Others  are  carried  off  sud- 
denly by  convulsions,  or  fall  victims  to  some  severe  paroxysm  of  spas- 
modic croup :  and  there  are  other  instances  in  which  the  disease  seems 
lighted  up  again,  after  a  pause,  by  the  irritation  of  teething,  or  by  some 
trivial  accident,  and  death  is  preceded  by  the  indications  of  acute 
cerebral  mischief. 

The  pathology  of  chronic  internal  hydrocephalus  involves  questions 
not  merely  of  scientific  interest,  but  of  great  practical  moment ;  for 
if  we  come  to  the  conclusion  at  which  some  observers  of  high  authority 
have  arrived,  that  it  is  almost  invariably  the  effect  of  arrest  of  the 
developement  of  the  brain,  all  therapeutical  proceedings  must  be  worse 
than  useless.  The  early  date  of  the  occurrence  of  its  symptoms,  in  the 
great  majority  of  cases,  lends  support,  indeed,  to  the  opinion  that  the 
causes  to  which  it  is  due  must  generally  have  existed  before  birth ;  for 
I  find,  on  examination  of  the  history  of  54  cases,  18  of  which  came 
under  my  own  observation,  that  some  indications  of  it  were  observed  in 
50  of  this  number,  before  the  child  was  six  months  old ;  that  in  14  of 
these  its  symptoms  existed  from  birth;  and  that  in  21  more,  they 
appeared  before  the  completion  of  the  third  month.  The  knife  of  the 
anatomist,  too,  has  discovered  evidences  of  congenital  malformation  of 
the  brain,  in  some  instances  in  which  no  sign  of  hydrocephalus  was 
apparent  until  several  weeks  after  the  child's  birth ;  a  fact  which  still 
further  deepens  the  dark  colours  in  which  this  malady  has  been  pour- 
trayed. 


94  PATHOLOGY  OF  CHRONIC  INTERNAL  HYDROCEPHALUS. 

Still,  large  as  is  the  proportion  of  cases  in  which  symptoms  of  chronic 
hydrocephalus  have  existed  from  birth,  I  am  disposed  to  believe  the 
exceptions  to  this  not  to  be  so  extremely  rare  as  some  imagine,  and  am 
further  of  opinion,  that,  even  in  cases  of  congenital  hydrocephalus, 
inflammation  of  the  lining  of  the  lateral  ventricles,  such  as  produces  it 
after  birth,  may,  in  some  instances  at  least,  have  excited  it  during 
foetal  life. 

In  six  post-mortem  examinations  of  children  affected  with  chronic 
internal  hydrocephalus,  who  died  at  the  respective  ages  of  16  months, 
3  years,  8  months,  19  months,  2  years,  and  3£  years,  I  found  the  corpus 
callosum  perfect  in  every  instance.  In  all,  also,  the  fornix  was  present ; 
thrice  it  and  the  septum  lucidum  were  thickened  and  tough ;  once  they 
were  found  torn  and  softened ;  acute  hydrocephalus  having  supervened 
on  the  chronic  disease.  Once  the  septum  lucidum  was  absent,  and 
once  both  it  and  a  large  portion  of  the  fornix  also  were  wanting.  In 
one  case  the  state  of  the  membranes  lining  the  ventricles  was  not  noted ; 
in  the  other  five  it  was  thickened,  four  times  very  remarkably ;  and 
twice  it  was  roughened  and  granular,  a  condition  which  is  also  occa- 
sionally to  be  seen  in  fatal  cases  of  acute  hydrocephalus. 

With  the  exception  of  one  instance  in  which  the  accumulation  of  a 
large  quantity  of  fluid  in  the  ventricles  coexisted  with  a  cancerous  tumor 
of  the  brain,  the  above  cases  constitute  the  whole  of  my  experience  of 
the  post-mortem  appearances  of  chronic  internal  hydrocephalus ;  and 
they  certainly  tend  to  support  the  opinion  that  its  connection  with 
inflammation  of  the  lining  of  the  ventricles  is  of  less  rare  occurrence 
than  some  observers  have  supposed.  The  granular  condition  of  the 
arachnoid  lining  the  ventricles  varies  from  a  very  slight  degree,  in  which 
it  is  perceptible  only  in  certain  lights,  and  scarcely  conveys  a  sense  of 
roughness  to  the  finger,  to  an  unevenness  as  marked  as  that  of  sha- 
green, or  even  to  a  condition  in  which  the  granulations  still  retaining 
their  transparency,  become  distinct,  slightly  prominent,  flattened  bodies, 
a  third  of  an  inch  or  more  in  diameter,  as  I  once  observed  them  to  be ; 
or  even  acquire,  as  Professor  Rokitansky  says,1  distinct  pedicles,  and 
hang  down  into  the  cavity  of  the  ventricles.  These  granulations  are, 
as  far  as  I  know,  usually  associated  with  traces  of  inflammation  of  the 
arachnoid  at  other  parts,  while  they  are  met  with  in  cases  where  the 
ventricles  contain  no  excess  of  fluid,  and  in  adults  as  well  as  in  children,3 
and  are  far  from  being  necessarily  connected  with  the  evidences  of 
tubercular  disease,  either  in  the  brain  or  in  other  parts  of  the  body. 
My  friend,  Dr.  Ormerod,  has  kindly  communicated  to  me  the  particulars 
of  six  cases  in  which  he  observed  this  granular  state  of  the  lining  mem- 
brane of  the  ventricles  in  the  adult;  and  in  every  instance  it  was 
associated  with  other  indications  of  old  inflammation  of  the  arachnoid. 
More  recently,  too,  my  friend  and  colleague,  Dr.  Kirkes,  from  his  large 
opportunities  of  observation  at  St.  Bartholomew's  Hospital,  has  fur- 
nished me  with  an  account  of  24  cases,  in  20  of  which  the  subjects  were 


1  Pathologische  Anatomie,  vol.  ii.  p.  748. 

2  The  condition  was,  I  believe,  first  noticed  by  Dr.  Bright  in  his  Medical  Reports, 
vol.  ii.  part  2,  p.  693. 


INTERNAL    HYDROCEPHALUS — MORBID  APPEARANCES.  95 

adults,  the  lining  of  whose  ventricles  presented  this  granular  condition 
in  a  more  or  less  marked  degree.  In  every  instance  it  was  associated 
with  other  morbid  appearances  in  the  'brain ;  and  in  16  of  the  number 
the  most  important  of  these  appearances  were  such  as  indicated  the 
arachnoid  in  other  parts  to  have  been  the  seat  of  inflammation.1 

In  some  cases — as,  for  instance,  in  this  drawing  by  Professor  Vrolik,2 
of  the  brain  of  a  young  man  who  died  of  chronic  hydrocephalus  at  the 
age  of  20, — a  false  membrane  is  found  in  the  interior  of  one  or  other 
ventricle,  and  may  even  occlude  the  foramen  of  Monro ;  an  accident 
which,  by  interrupting  the  communication  between  the  two  sides  of  the 
brain,  may  serve  to  account  for  the  unequal  distension  of  the  two  ven- 
tricles, and  the  great  want  of  symmetry  occasionally  observed  in  hydro- 
cephalic skulls.  The  marks  of  inflammation  of  the  membranes  at  the 
base  of  the  brain  are,  moreover,  in  many  instances,  very  evident ;  and 
there  is  often  an  extremely  abundant  effusion  of  that  hyaline  matter  in 
the  meshes  of  the  pia  mater,  to  which  I  called  your  attention  when 
speaking  of  acute  hydrocephalus. 

Lastly,  I  may  remark,  that  the  observation  in  a  large  number  of 
instances,  that  the  cerebral  substance  has  been  simply  unfolded  by  the 
accumulation  of  the  fluid  in  the  ventricles,  so  that  even  when  of  extreme 
tenuity,  the  gray  and  white  substance  could  still  be  distinguished,  proves 
not  merely  that  the  brain  was  not  melted  down  by  the  action  of  the 
fluid,  but  also  that  its  accumulation  could  not,  in  these  instances,  be 
due  to  the  arrest  of  cerebral  development. 

Besides  the  evidence  which  post-mortem  examinations  often  furnish 
of  the  connection  of  chronic  internal  hydrocephalus  with  previous  in- 
flammatory action,  the  history  of  the  patient's  illness  sometimes  affords 
distinct  proof  of  its  occurrence.  A  striking  instance  of  this  has  been 
lately  published  by  M.  Rilliet,  of  Geneva,3  in  the  case  of  a  little  girl 
10|  years  old,  in  whom  the  symptoms  of  acute  cerebral  inflammation 
were  succeeded  by  those  of  chronic  disease  in  the  brain,  which  termi- 
nated fatally  at  the  end  of  four  months.  Ten  ounces  of  transparent 
but  highly  albuminous  fluid  were  contained  in  the  lateral  ventricles,  the 
lining  membrane  of  which  was  nearly  half  a  line  thick,  having  a  gela- 
tinous appearance,  as  if  softened,  but  being  in  reality  so  tough  that  it 
could  be  torn  away  from  the  cerebral  substance  in  long  strips. 

Though  in  the  following  history  the  connection  between  the  acute 
and  the  chronic  evil  is  far  less  striking  than  in  M.  Billiet's  case,  yet  I 
think  few  would  refuse  to  admit  the  injury  to  the  head  and  the  subse- 
quent cerebral  symptoms  as  the  first  steps  in  the  chain  of  morbid  pro- 
cesses which  led  to  the  distension  of  the  ventricles  of  the  brain  with 
fluid,  and  to  the  development  of  all  the  symptoms  of  chronic  hydro- 
cephalus. 

1  Of  the  34  cases  on  which  the  above  statements  are  founded,  8  occurred  in  children, 
under  10  years  old;  the  remainder  in  persons  of  18  and  upwards.  In  11  instances,  6 
of  which  occurred  in  children,  the  granular  condition  of  the  lining  of  the  ventricles  was 
associated  with  tubercular  disease  of  the  brain  or  its  membranes ;  and  in  two  others 
tubercle  was  deposited  in  other  organs;  but  in  the  remaining  21  cases  neither  of  these 
complications  existed. 

2  Traite"  sur  la  Hydrocephalic  Interne,  4to.  plate  iii.    Amsterdam,  1839. 

3  Archives  Gen.  de  M6decine,  Dec.  1847. 


96  INTERNAL   HYDROCEPHALUS — MORBID   APPEARANCES. 

A  little  girl,  the  child  of  healthy  parents,  was  healthy  when  born, 
and  continued  so  until  she  was  five  months  old,  when  she  fell  out  of  the 
arms  of  the  person  who  was  nursing  her,  and  on  the  same  day  was 
taken  in  a  fit,  and  lay  stupid  and  senseless  for  some  hours.  She  was 
leeched  and  blistered  for  these  and  other  head  symptoms  which  the 
parents  were  unable  to  describe  very  accurately,  and  to  all  appearance 
recovered.  When  a  year  old,  however,  head  symptoms  returned,  and 
for  several  weeks  convulsions  were  of  extremely  frequent  occurrence; 
but  at  length  ceased.  About  that  time,  the  child  being  then  15  months 
old,  her  mother  first  noticed  that  her  head  was  beginning  to  enlarge, 
since  which  time  she  had  had  no  return  of  fits,  but  the  head  continued 
to  increase  in  size  down  to  the  time  when  I  first  saw  her,  she  being 
then  just  three  years  old. 

Her  countenance  presented  all  the  peculiarities  of  chronic  hydroceph- 
alus in  a  very  marked  degree :  her  head  was  large,  measuring  20  inches 
in  circumference,  and  13J  from  one  meatus  auditorius  to  the  other ;  her 
forehead  was  prominent,  and  her  eyes  were  directed  downwards,  while 
her  body  was  very  ill  nourished.  Her  bowels  were  regular,  her  bodily 
functions  generally  natural,  and  she  was  very  voracious.  She  was  by 
no  means  stupid,  but  on  the  contrary,  shewed  much  shrewdness,  though 
she  was  noisy,  and  almost  constantly  chattering. 

I  had  not  seen  her  above  once  or  twice  when  she  was  attacked  with 
measles,  on  the  second  day  of  which  convulsions  came  on,  and  she  sank 
into  a  comatose  state,  interrupted  only  by  convulsive  twitchings  of  the 
limbs,  and  died  in  this  condition  on  the  fourth  day  of  her  illness. 

The  head  was  examined  48  hours  after  death. 

The  bones  of  the  cranium  were  quite  firm  and  hard ;  the  posterior 
fontanelle  was  closed,  but  the  anterior  was  open ;  its  diameter  in  either 
direction  being  about  3J  inches. 

There  was  no  fluid  in  the  sac  of  the  arachnoid,  nor  any  morbid  con- 
dition of  the  membranes  either  at  the  vertex  or  base  of  the  brain. 

A  very  small  quantity  of  fluid  was  in  the  sub-arachnoid  tissue,  and 
a  pint  of  perfectly  transparent  serum  in  the  lateral  ventricles. 

The  convolutions  of  the  brain  were  quite  flattened :  its  cortical  sub- 
stance of  natural  thickness,  the  white  substance  very  thin,  and  expan- 
ded around  the  ventricles,  which  were  dilated  to  four  times  their  natural 
size. 

The  white  substance  of  the  wall  of  the  ventricles  was  quite  firm,  and 
separable  into  a  thin  tough  layer,  leaving  the  substance  of  the  brain 
quite  natural  beneath.  The  septum  lucidum  was  tough  and  membranous, 
and  much  thickened.  The  edges  of  the  fornix  were  firmly  adherent  to 
the  upper  surface  of  the  optic  thalamus,  and  included  between  them  a 
portion  of  the  choroid  plexus. 

The  membrane  lining  the  ventricles  was  universally  thickened ;  where 
it  covered  the  corpora  striata,  the  optic  thalami,  the  commissures,  and 
the  floor  of  the  fourth  ventricle,  it  was  not  only  peculiarly  tough,  but 
granular,  and  presented  an  appearance  just  like  shagreen. 

The  size  of  the  head  in  this  case  had  been  increasing  but  slowly,  and 
probably,  had  the  child  not  been  cut  off  by  the  intercurrent  attack  of 
measles,  the  effusion  of  fluid  would  at  length  have  come  to  a  stand-still, 


INTERNAL   HYDROCEPHALUS— MORBID   APPEARANCES.  97 

and  the  hydrocephalus  would  have  been  cured  ;  at  least,  as  much  as  hydro- 
cephalus usually  is.  Strictly  speaking,  however,  there  is  in  general  no 
cure  of  the  affection,  but  merely  an  arrest  of  its  progress :  no  more 
fluid  is  poured  out,  but  that  already  effused  is  unabsorbed ;  the  sutures 
and  fontanelles  become  ossified,  and  the  enormous  size  of  the  head 
attracts  leSs  attention,  not  because  there  is  any  diminution  in  its  dimen- 
sions, but  because  the  disproportion  between  the  cranium  and  the  face 
becomes  less  striking  owing  to  the  development  of  the  latter  as  the  child 
grows  older.  In  some  instances,  indeed,  Professor  Otto1  is  of  opinion 
that  a  real  cure  is  effected  by  an  increased  activity  of  the  nutrition  of 
the  brain  producing  hypertrophy  of  the  organ ;  the  fluid  being  absorbed, 
and  nervous  matter  deposited  in  its  stead.  This,  however,  is  in  all 
probability  a  purely  exceptional  occurrence ;  and  the  majority  of  hydro- 
cephalic patients  who  survive  the  advance  of  the  disease  still  have  their 
lateral  ventricles  distended  with  fluid.  This  was  all  that  occurred  in 
the  well-known  case  of  Thomas  Cardinal,  whose  bust  I  here  show  you, 
Having  been  hydrocephalic  from  infancy,  he  yet  lived  to  the  age  of  29, 
in  the  possession  of  a  tolerable  amount  of  bodily  and  mental  activity. 
On  examination  of  his  body  after  death,  between  seven  and  eight  pints 
of  fluid  were  found  in  his  cranium.  In  the  greater  number  of  instances 
symptoms  exist  during  life  which  show  clearly  enough  that  the  arrest 
of  the  disease  differs  widely  from  its  cure,  or  that  the  malady  of  the 
brain  which  it  produces,  or  with  which  it  was  associated,  is  irreparable,  for 
the  intellectual  powers  are  generally  feeble,  and  the  temper  very  irritable, 
while  the  child  is  often  unable  to  walk,  and  its  sight  is  very  imperfect. 

The  presence  of  a  large  quantity  of  fluid  in  the  sac  of  the  arachnoid, 
constituting  what  is  called  external  hydrocephalus,  may  arise  from 
several  causes. 

1st.  The  commissures  of  the  distended  brain  may  yield,  and  a  portion 
or  the  whole  of  the  fluid  which  it  contained  may  escape  into  the  cavity 
of  the  cranium.  This  seems  to  have  taken  place  in  the  case  of  Cardi- 
nal, whose  skull  contained  seven  or  eight  pints  of  fluid,  while  "the 
brain  lay  at  its  base,  with  its  hemispheres  opened  outwards  like  the 
leaves  of  a  book."2 

2d.  An  atrophied  condition  of  the  brain  may  exist,  and  fluid  may  be 
poured  out  to  fill  up  the  vacuum  thus  produced  in  the  skull ;  and  such 
cases  are  generally  of  a  very  hopeless  kind,  the  defect  of  cerebral 
development  being  almost  always  the  result  of  congenital  malformation 
or  intra-uterine  disease. 

3d.  A  large  quantity  of  fluid  is  sometimes  found  in  the  sac  of  the 
arachnoid,  as  the  result  of  haemorrhage  into  its  cavity,  and  of  the 
changes  subsequently  undergone  by  the  effused  blood.  MM.  Rilliet  and 
Barthez,  who  have  most  ably  investigated  the  subject  of  haemorrhage 
into  the  arachnoid,  believe  that  chronic  hydrocephalus  frequently  has 
this  origin.  I  have  seen  a  few  cases  which  I  suspect  were  of  this 
nature,  but  have  never  had  the  opportunity  of  confirming  my  suspicions 
by  a  post-mortem  examination. 

1  Rokitansky's  Pathologische  Anatomie,  vol.  ii.  p.  749—769. 

2  Brigkt's  Reports,  vol.  i.  part  1,  p.  433. 


98  TREATMENT  OF  CHRONIC  HYDROCEPHALUS. 

In  cases  of  this  last  kind,  more  may  be  expected  both  from  nature's 
own  reparative  powers,  and  from  the  resources  of  art,  than  in  any  other 
form  of  chronic  hydrocephalus.  Unfortunately,  their  symptoms,  as  I 
stated  at  the  beginning  of  this  lecture,  so  closely  resemble  those  of  the 
other  less  hopeful  varieties  of  the  disease,  that  their  diagnosis  is  atten- 
ded with  much  difficulty  and  uncertainty,  and  must  be  founded,  in  great 
measure,  on  the  previous  history  of  the  patient.  "It  is  never  congeni- 
tal, but  generally  begins  about  the  tenth  month ;  that  is  to  say,  about 
the  time  when  the  teeth  begin  to  appear.  The  head,  indeed,  enlarges 
gradually,  but  does  not  acquire  so  large  a  size  as  in  internal  hydroce- 
phalus :  while  lastly,  it  is  always  preceded  by  repeated  convulsions,  or 
by  some  other  form  of  active  cerebral  disturbance,  which  marks  the 
date  of  the  occurrence  of  haemorrhage."1 

The  obsenation  has  often  been  made,  that  the  reputed  means  of  cure 
of  any  disease  are  generally  numerous  in  a  directly  inverse  proportion 
to  its  curability ;  and  to  this  rule  chronic  hydrocephalus  certainly  forms 
no  exception:  "its  remedies  have  been  derived,"  as  Golis  says,  "  from 
all  the  kingdoms  of  nature,  and  include  almost  every  kind  of  surgical 
contrivance  and  pharmaceutical  compound."  It  would  be  an  almost 
endless  task  to  attempt  estimating  the  comparative  value  of  them  all ; 
and  I  think  it  more  useful  to  direct  your  attention  to  a  few  points  of 
real  importance. 

First  of  all,  I  would  have  you  bear  in  mind  that  there  are  some  cases 
in  which  you  can  do  no  permanent  good,  but  in  which  treatment  must 
fail,  not  because  it  is  improper,  but  because  the  malady  does  not  admit 
of  cure.  Such  cases  are  those  in  which  the  accumulation  of  fluid  within 
the  brain  is  associated  with  extensive  congenital  disease,  or  malforma- 
tion of  the  organ.  If  aware  of  its  existence,  our  treatment  would,  of 
course,  be  simply  palliative,  and  our  efforts  would  be  limited  to  securing 
euthanasia,  since  we  could  not  hope  to  avert  death.  We  should  suspect 
the  affection  to  be  incurable,  if,  though  the  head  were  large,  and  its 
ossification  very  imperfect,  the  forehead  were  low  and  shelving ;  if  a 
considerable  degree  of  paralysis  were  present,  if  convulsions  occurred 
daily  and  causelessly,  and  especially  if  these  or  other  indications  of 
serious  cerebral  disorder  had  existed  almost  from  birth.  Unfortunately, 
these  hopeless  cases  are  by  no  means  invariably  characterized  by 
peculiar  symptoms,  and  the  amount  of  functional  disturbance  often 
affords  but  a  very  incorrect  index  to  the  extent  of  organic  lesion  :  your 
prognosis,  therefore,  must  always  be  most  guarded,  and  even  when  you 
see  every  reason  to  expect  success,  you  must  yet- be  prepared  for  failure. 

On  the  other  hand,  you  must  not  regard  a  case  as  hopeless,  and 
abstain  from  remedial  measures,  merely  on  account  of  the  head  having 
been  larger  than  natural  at  birth,  or  its  ossification  having  been  less 
advanced  than  usual,  since  we  have  evidence  of  perfect  recovery  from 
chronic  hydrocephalus  in  cases  where  many  circumstances  had  appeared 
to  indicate  that  the  disease  was  congenital.  The  state  of  the  cerebral 
functions  must  influence  your  prognosis  as  much  as  the  size  of  the  head, 
or  even  more. 

1  Legendre,  Recherclies  Anatomo-pathologiques,  p.  135.  See  also  Rilliet  et  Bartliez, 
op.  cit.  yoI.  ii.  p.  46. 


GOLIS'S   PLAN — COMPRESSION   OF   THE   HEAD.  9$ 

In  either  form  of  chronic  hydrocephalus,  the  success  of  treatment 
mnst  depend,  to  a  great  degree,  upon  its  being  adopted  early,  but  in 
no  stage  of  the  disease  can  good  be  expected  from  violent  remedies  ; 
rough  measures  would  be  likely  to  destroy  the  patient  rather  than  the 
malady.  I  do  not  know  of  any  plan,  on  the  whole,  more  likely  to  be 
of  service,  than  that  which  Professor  Golis,  of  Vienna,  recommended 
as  the  result  of  many  years'  experience.  He  advises  that  the  head  of 
the  child  be  shorn,  or  its  hair  cut,  close,  and  that  one  or  two  drachms 
of  the  mild  mercurial  ointment  be  rubbed  daily  into  its  scalp.  At  the 
same  time,  the  head  is  to  be  kept  constantly  covered  with  a  flannel  cap,  to 
prevent  the  risk  of  the  perspiration  being  checked  by  the  cold  air,  and 
gr.  J,  or  gr.  ss.  of  calomel,  should  be  given  twice  a  day,  unless 
diarrhoea  come  on,  when  the  inunction  alone  must  be  employed.  This 
plan  should  be  persevered  in  for  thirty  or  forty  days,  when,  if  the 
patient  appear  improving,  the  remedies  may  be  very  gradually  dimin- 
ished, but  the  cap  should  be  still  worn  even  after  the  inunction  has 
been  discontinued.  Should  no  great  improvement  appear  after  a  lapse 
of  six  or  eight  weeks,  some  mild  diuretic  may  be  conjoined  with  the  other 
remedies,  and  a  couple  of  issues  may  be  inserted  in  the  occiput.  For 
this  measure,  however,  I  have  always  substituted  the  frequent  appli- 
cation of  blisters  to  the  back  of  the  neck. 

The  woollen  cap,  recommended  by  Golis,  often  seems  agreeable  to 
the  child,  but  sometimes  I  have  had  to  discontinue  it,  in  consequence 
of  the  heat  of  head  which  it  produced.  In  most  cases,  too,  you  will 
be  compelled  to  resort  to  occasional  leeching,  in  order  to  subdue  the 
attacks  of  heat  of  head  and  restlessness,  which  are  exacerbated  from 
time  to  time,  and  often  attended  with  other  symptoms  that  threaten  the 
supervention  of  acute  disease. 

The  observation  that  in  some  cases  where  spontaneous  cure  of  a 
chronic  hydrocephalus  takes  place,  the  ossification  of  the  head,  pre- 
viously so  imperfect,  makes  rapid  advances,  and  the  bones  become  early 
united,  led  Mr.  Barnard,1  of  Bath,  to  imitate  nature's  processes,  and 
to  bandage  the  head  so  as  to  prevent  its  yielding  to  the  accumulating 
fluid.  He  has  related  several  cases  of  the  successful  adoption  of  this 
practice,  though,  like  many  other  persons,  he  rides  his  hobby  rather 
too  hard,  aud  advocates  his  mechanical  method  to  the  exclusion 
of  all  other  treatment.  It  is,  however,  a  valuable  adjunct  to  other 
treatment  in  some  cases.  Unless  you  apply  it  well  it  will  be  of  little 
service,  and  the  plasters  by  which  the  compression  is  exerted  will  come 
off.  You  cannot  do  better  than  follow  M.  Trousseau's  rules  for  their 
application.2  He  uses  strips  of  diachylon  plaster  about  one-third  of 
an  inch  broad ;  and  applies  them — 1st,  from  each  mastoid  process  to 
the  outer  part  of  the  orbit  of  the  opposite  side ;  2d,  from  the  hair 
at  the  back  of  the  neck  along  the  longitudinal  suture  to  the  root  of  the 
nose ;  3d,  across  the  whole  head,  in  such  a  manner  that  the  different 
strips  shall  cross  each  other  at  the  vertex ;  4th,  a  strip  is  cut  long 
enough  to  go  thrice  around  the  head.     Its  first  turn  passes  over  the  eye 

1  Cases  of  Chronic  Hydrocephalus,  &c.  by  J.  H.  Barnard,  8vo.  London,  1839. 
8  Journal  de  MSdecine,  April  1843. 


100     PUNCTURE  OP  THE  HEAD  IN  CHRONIC  HYDROCEPHALUS — 

brows,  above  the  ears,  and  a  little  below  the  occipital  protuberance,  so 
that  the  ends  of  all  the  other  strips  shall  project  about  one-fourth  of 
an  inch  below  the  circular  strip.  These  ends  are  next  doubled  up  on 
the  circular  strip,  and  its  remaining  two  turns  are  then  to  be  passed 
over  them  just  in  the  same  direction  as  the  first  turn.  By  this  means 
you  secure  a  firm,  and  equal,  and  very  powerful,  pressure  on  the  head. 
You  must  watch  the  results  of  this  proceeding  very  carefully,  and 
loosen  the  plasters  if  symptoms  of  compression  appear,  since  it  once 
happened  to  M.  Trousseau,  from  neglect  of  this  precaution,  that  the 
fluid  acted  on  the  base  of  the  skull,  detaching  the  ethmoid  bone  from 
its  connections,  and  thus  occasioned  the  infant's  death. 

You  will  naturally  inquire  whether  pressure  is  applicable  to  every 
case,  and  if  not,  when  should  it  be  employed  ?  I  regret  that  I  cannot 
answer  these  inquiries  so  satisfactorily  as  I  could  wish.  It  is  my  belief, 
however,  that  cases  of  external  hydrocephalus,  which  have  succeeded 
to  previous  haemorrhage  into  the  arachnoid,  would  be  found  better 
adapted  than  any  others  to  treatment  by  mechanical  means  ;  while  I 
am  quite  sure,  from  actual  experience,  that  when  there  is  any  appear- 
ance of  active  cerebral  disease,  pressure  will  not  do  good. 

Puncture  of  the  cranium,  and  the  evacuation  of  the  fluid,  is  another 
proceeding  which  has  been  occasionally  resorted  to  from  a  very  early 
period  in  the  history  of  medicine,  and  which  is  even  at  the  present  day 
strongly  advocated  by  some  writers  ;  not  merely  as  a  palliative  measure; 
or  as  an  adjunct  to  other  remedies,  but  as  a  means  of  effecting  the 
radical  cure  of  the  disease.  Opinion,  however,  is  much  divided  as  to 
the  propriety  of  this  practice,  the  statistics  of  which  certainly  do  not 
yield  any  very  encouraging  results.  Fify-six  cases,  the  particulars  of 
which  I  published  some  years  ago,1  as  I  found  them  recorded  in  various 
publications,  yielded  a  proportion  of  fifteen  alleged  recoveries  ;  but  Jon 
subjecting  these  cases  to  a  rigid  analysis,  it  appeared  that  in  only  four 
of  this  number  were  the  particulars  recorded  with  sufficient  accuracy, 
or  had  the  interval  since  the  performance  of  the  operation  been  long 
enough  to  warant  our  admitting  them  as  permanent  cures.  The  very 
unfavourable  conclusions  which  I  then  expressed  with  reference  to  this 
operation  were  afterwards  criticised  by  M.  Durand-Fardel,2  a  gentle- 
man whose  opinion  on  any  question  connected  with  cerebral  disease  is 
entitled  to  very  great  weight.  He  observed,  that  while  it  is  admitted 
that  in  a  few  cases  puncture  of  the  cranium  has  been  followed  by  com- 
plete and  permanent  cure,  its  failure  on  other  occasions  was  often  mani- 
festly due  to  the  existence  of  utterly  incurable  malformation  of  the  brain ; 
while  in  very  many  instances,  though  the  operation  failed  to  effect  a 
cure,  yet  the  very  frequency  with  which  it  was  repeated  proved  that 
in  itself  it  is  not  usually  attended  with  any  considerable  danger.  Since, 
then,  it  may  do  good, — since,  if  it  should  fail,  its  failure  is  often  due  to 
causes  which  no  remedy  could  remove, — since,  even  if  it  should  do  no 
good,  yet  in  the  majority  of  instances  it  will  do  no  harm,  while  if  left 
to  itself  the  course  of  the  disease  is  almost  invariably  to  a  fatal  result, 

1  In  the  Medical  Gazette,  April  1842. 

2  In  the  Bulletin  G<5n<Srale  de  ThOapeutique,  vol.  xxiii.  p.  190. 


CASES   SUITED   FOR   IT.  101 

he  advocates  its  performance  in  cases  of  chronic  hydrocephalus.  Though 
I  cannot  but  fear  that  this  gentleman  rather  underrates  the  amount  of 
immediate  risk  attendant  on  the  operation,  yet  I  think  that  his  authority 
ought  at  least  to  have  so  much  weight  with  you  as  to  prevent  your 
looking  upon  its  performance  as  altogether  unjustifiable,  and  the  rather 
since  there  is  good  reason  for  believing  that  the  accumulation  of  fluid 
in  the  ventricles  is  frequently  the  result  of  previous  inflammation  of 
their  lining  membrane,  and  that  puncture  of  the  cranium  may  therefore 
contribute  to  the  cure  of  dropsy  of  the  brain,  just  as  tapping  the  abdo- 
men does  to  the  cure  of  ascites.1 

I  should  regard  any  case  as  favourable  for  the  operation,  which,  on  the 
whole,  there  was  good  ground  for  believing  to  be  one  of  external  hydro- 
cephalus, or  in  which  the  enlargement  of  the  head  had  not  been  attended 
with  indications  of  active  cerebral  disease.  Though  less  promising, 
I  should  not  reject  the  operation  simply  because  enlargement  of  the 
head  had  been  congenital ;  while  I  should  always  be  more  ready  to 
operate  if  nutrition  were  well  performed  than  if  the  child  were  emaciated. 
I  would  not,  however,  have  you  operate  simply  because  the  head  is  large  ; 
for  it  does  not  appear  that  diminution  in  its  size  has  resulted  from  the 
puncture,  but  only  arrest  of  its  enlargement ;  and  if  the  disease  be  at  a 
stand-still,  and  the  cerebral  functions  tolerably  well  performed,  you 
would  risk  much  with  the  chance  of  gaining  but  very  little. 

The  proper  situation  for  the  puncture  is  the  coronal  suture,  about  an 
inch  or  an  inch  and  a  half  from  the  anterior  fontanelle.  A  fine  trocar 
and  canula  are  the  best  instruments ;  and  care  must  be  taken  not  merely 
to  withdraw  only  a  very  few  ounces  of  fluid  at  a  time,  but  to  keep  up 
pressure  both  during  the  escape  of  the  fluid  as  well  as  afterwards. 


LECTURE  IX. 


Hypertrophy  op  the  Brain — usually  associated  -with  general  disorder  of  nutrition — 
symptoms  and  course — seldom  directly  fatal — nature  of  change  in  brain — alterations 
in  form  "of  skull,  and  difference  from  chronic  hydrocephalus — Treatment — Partial 
hypertrophy. 

Atrophy  op  the  brain — case  illustrative  of  its  defective  developement — Wasting  of  the 
brain  in  protracted  illness. — Temporary  retrocession  of  mental  powers  in  children 
after  long  illness. — Case  of  partial  atrophy. 

The  anxiety  of  parents  is  sometimes  needlessly  excited  in  consequence 
of  an  infant's  head  being  larger  than  common,  and  even  though  the 
child's  health  be  good  the  relations  are  apprehensive  lest  it  should  be 
affected  with  water  in  the  brain.  Now  you  must  not  be  too  ready  to  take 
up  this  cry,  which  is  one  often  raised  by  nurses  and  ignorant  persons,  or  to 
suppose  that  every  large  head  is  therefore  unnatural ;  for  one  child  may 
have  a  bigger  head  than  another,  just  as  it  may  have  a  bigger  hand  or 

1  See,  moreover,  some  remarks  on  this  operation,  and  cases  of  its  successful  perform- 
ance, in  the  Oesterr.  Med.  Jahrbucher,  vol.  xxii.  p.  27,  by  Dr.  Schopf-Merei,  now  of 
Manchester,  late  the  distinguished  director  of  the  Children's  Hospital  at  Pesth. 


102  HYPERTROPHY  OP  THE  BRAIN. 

foot.  But  it  may  be  that  the  child's  head  is  not  only  larger  than 
natural,  but  that  well-marked  symptoms  of  cerebral  disturbance  are 
present,  and  you  may  feel  yourselves  compelled  to  adopt  the  opinion 
that  the  case  is  one  of  incipient  chronic  hydrocephalus.  The  subsequent 
history  of  the  patient  may  in  many  respects  confirm  your  original  diag- 
nosis, so  that  great  will  be  your  surprise,  on  examining  the  body  after 
death,  at  not  finding  a  drop  of  serum  in  the  ventricles,  although,  when 
you  opened  the  skull,  the  cerebral  convolutions  had  appeared  flattened, 
as  if  the  brain  were  greatly  distended  with  fluid. 

Individual  cases  of  this  kind  had  been  mentioned  by  medical  writers  at 
different  times,  but  Laennec1  was  the  first  who  drew  attention  to  hyper- 
trophy of  the  brain  as  a  condition  resembling  chronic  hydrocephalus 
in  many  of  its  symptoms,  and  liable  to  be  mistaken  for  it.  It  has  since 
then  been  frequently  noticed,  and  I  am  not  sure  that  an  undue  impor- 
tance has  not  sometimes  been  attached  to  it,  as  though  it  were  of  much 
more  common  occurrence  than  you  will  really  find  it  to  be  in  practice. 

I  have  placed  upon  the  table  a  cast  taken  from  the  head  of  a  child 
who  was  affected  with  hypertrophy  of  the  brain,  and  whose  very  remark- 
able case  is  related  by  Dr.  Watson.2  He  came  under  the  care  of  the 
late  Dr.  Sweatman  when  two  years  old,  and  his  head,  which  had  been 
gradually  increasing  from  the  age  of  six  months,  was  then  so  large  as 
by  its  weight  to  prevent  the  child  from  continuing  long  in  the  upright 
posture.  The  boy  was  active  and  lively,  though  thin.  He  had  never 
any  fit  or  convulsion,  but  occasionally  seemed  uneasy,  and  would  then 
relieve  himself  by  laying  his  head  upon  a  chair.  He  had  never  squinted, 
nor  was  he  subject  to  drowsiness  or  starting  during  sleep,  and  his 
pupils  contracted  naturally.  His  appetite  was  good,  and  all  the  animal 
functions  were  well  performed.  The  case  was  supposed  to  be  one  of 
chronic  hydrocephalus,  but  no  urgent  symptoms  being  present,  active 
remedies  were  not  employed.  About  six  months  afterwards  the  child 
died  of  inflammation  of  the  chest,  and  Dr.  Sweatman  examined  the 
head.  It  measured  12  inches  from  ear  to  ear  over  the  vertex,  13  inches 
from  the  superciliary  ridges  to  the  occipital,  and  21  inches  in  circum- 
ference. The  anterior  fontanelle,  which  was  quite  flat,  measured  2\ 
inches  by  1J-  across  its  opposite  angles ;  the  posterior  fontanelle  was 
completely  closed,  as  was  the  frontal  suture.  The  skull  generally  was 
increased  in  thickness ;  the  morbid  appearances  in  the  membranes  of  the 
brain  were  quite  trivial ;  the  ventricles  were  empty,  not  dilated  ;  the  con- 
volutions were  perfectly  distinct,  and  retained  their  proper  rounded  shape. 
The  medullary  matter,  however,  presented  a  very  unusual  vascularity. 

It  is  not  merely  on  account  of  the  great  size  which  the  head  attained 
that  I  have  quoted  this  history,  but  because  it  affords  an  instance  of 
the  overgrowth  of  the  brain  unconnected  with  any  general  disorder  of 
the  process  of  nutrition.  Such  an  occurrence  is  very  rare,  for  hyper- 
trophy of  the  brain  is  usually  only  one  manifestation  of  a  deep-seated 
disorder  of  the  nutritive  process,  and  is  met  with,  in  connection  with 
rickets  or  scrofula,  in  the  narrow  lanes  of  a  crowded  city,  or  in  the 

1  Journal  de  Mddecine,  Chirugie,  et  Pharmacie,  1806.  t.  xi.  p.  669. 

2  Lectures,  vol.  i.  p.  413. 


SYMPTOMS   OP   HYPERTROPHY   OF   THE   BRAIN.  103 

unhealthy  valleys  of  mountainous  districts,  where  goitre  and  cretinism 
are  endemic. 

The  majority  of  cases  of  hypertrophy  of  the  brain  that  have  come 
under  my  notice  in  London,  have  occurred  in  infants  about  six  or  eight 
months  old.     Their  history  has  usually  been,  that  without  any  definite 
illness,  they  had  lost  their  appetite,  and  grown  by  degrees  dull  and 
apathetic,  though  restless  and  uneasy.     Notwithstanding  the  general 
apathy,  this  restlessness  is  often  very  considerable,  though  it  does  not 
show  itself  in  cries  so  much  as  in  a  state  of  general  uneasiness,  and  in 
frequent   startings   from  sleep.     Short  gleams  of  cheerfulness    occur 
when  the  children  are  awake,  but  these   are  usually  very  transient. 
The  head  seems  too  heavy  to  be  borne,  and  even  when  its  size  is  not 
much  greater  than  natural  it  hangs  backwards,  or  to  one  side,  as  if 
the  muscles  were  too  weak  to  support  it.     If  placed  in  its  cot,  a  child 
who  is  thus  affected  bores  with  its  occiput  in  the  pillow,  while  its  head  is 
almost  constantly  in  a  state  of  profuse  perspiration.    Convulsions  some- 
times occur  without  any  evident  cause,  but  threatenings  of  their  attack 
are  much  more  frequent  than  their  actual  occurrence,  the  child  awaking 
suddenly  with  a  start  and  a  peculiar  cry,  like  that  of  spasmodic  croup, 
the  surface  turning  livid,  and  the  respiration  becoming  difficult  for  a 
few  moments,  and  the  symptoms  then  subsiding  of  their  own  accord. 
Such  attacks  may  issue  in  general  convulsions,  which  may  terminate 
fatally ;  but  infants  thus  affected  do  not  by  any  means  invariably  die  of 
the  cerebral  disorder,  but  being  weakly,  they  are  often  cut  off  by  the 
first  malady  which  attacks  them. 

If  life  be  prolonged,  it  becomes  more  and  more  evident  that  the  pro- 
cess of  nutrition  is  imperfectly  performed:  the  child  loses  flesh,  and 
looks  out  of  health,  the  enlargement  of  the  wrists  and  ankles  shows  the 
connection  between  this  disease  and  rickets, — a  connection  which 
becomes  more  evident  in  the  second  and  third  years  of  the  child's  life. 
When  the  child  survives  infancy,  or  when,  as  occasionally  happens,  the 
symptoms  of  hypertrophy  of  the  brain  do  not  come  on  until  dentition 
has  been  in  a  great  measure  accomplished,  convulsions  are  of  very  rare 
occurrence.  Complaints  of  headache,  however,  are  frequent  and  severe : 
and,  though  drowsy  in  the  day-time,  the  child  generally  rests  ill  at 
night,  and  often  awakes  crying  and  alarmed.  Besides  these  symptoms, 
too,  the  child  has  occasional  attacks  of  feverishness,  with  great  increase 
of  the  headache,  and  giddiness,  which  lasts  for  a  few  hours  or  a  day, 
and  then  subside  of  their  own  accord,  while  it  grows  by  degrees  more 
and  more  dull  and  listless,  and  its  mental  powers  become  obviously 
impaired. 

It  happens  in  some  cases,  that  as  the  child  grows  older,  these  symp- 
toms become  less  and  less  severe ;  the  health  improves,  the  rickety 
deformity  of  the  limbs  gradually  disappears,  and  the  infant  who  had 
excited  so  much  solicitude  becomes  at  length  a  healthy  child.  There 
is  a  termination  in  complete  idiocy,  which  I  have  never  seen  in  this 
country,  but  a  few  years  ago  I  observed  some  instances  of  it  in  the 
Hospital  for  Cretins,  near  Interlachen;  and  Dr.  Guggenbiihl,  the 
director  of  the  institution,  informed  me  that  the  association  of  cretinism 
and  idiocy  with  hypertrophy  of  the  brain  is  by  no  means  of  unusual 


104  ITS   DIAGNOSIS   FROM   CHRONIC   HYDROCEPHALUS. 

occurrence.  Death  is  not  often  the  direct  result  of  the  affection  of 
the  brain,  but  generally  takes  place  owing  to  the  supervention  of  some 
other  disease.  The  affections,  however,  which  prove  most  fatal  are 
those  which  favour  cerebral  congestion, — such  as  hooping-cough,  or  the 
eruptive  fevers,  especially  scarlatina. 

You  must  not  infer  that  hypertrophy  of  the  brain  has  existed  in 
every  instance  in  which  the  organ  may  appear  to  be  large,  and  its 
convolutions  somewhat  flattened,  although  the  ventricles  are  free  from 
fluid.  The  weight  and  apparent  size  of  the  brain  are  much  influenced 
by  the  quantity  of  blood  contained  within  it,  and  it  may  appear  too 
large  for  the  skull  simply  because  its  vessels  are  over-full.1  In  true 
hypertrophy,  on  the  contrary,  the  brain  is  generally  pale  and  anaemic, 
unless  death  should  chance  to  have  taken  place  as  the  result  of  an  attack 
of  cerebral  congestion.  Neither,  indeed,  is  the  process  one  of  mere 
increased  growth,  but  the  nutrition  of  the  organ  is  modified  in  character 
as  well  as  increased  in  activity.  The  grey  matter  of  the  brain  is  but 
little  involved  in  it,  and,  with  the  exception  of  its  colour  being  some- 
what paler  than  natural,  it  shows  scarcely  any  alteration.  The  white 
matter,  on  the  contrary,  is  both  paler  and  firmer  than  in  a  state  of 
health  ;  and  Professor  Rokitansky2  states,  as  the  result  of  many  micro- 
scopical examinations,  that  its  augumented  bulk  is  not  produced  either 
by  the  development  of  new  nervous  fibrils,  or  by  the  enlargement  of 
those  already  existing,  but  by  an  increase  in  the  intermediate  granular 
matter.  These  changes,  too,  do  not  affect  indifferently  all  parts  of 
the  brain,  but  are  confined  to  the  hemispheres,  and  do  not  implicate 
either  the  base  of  the  organ  or  the  cerebellum. 

Chronic  hydrocephalus  is  the  only  affection  with  which  hypertrophy 
of  the  brain  is  liable  to  be  confounded :  the  diagnosis  between  the  two 
affections  is  often  by  no  means  easy,  though  it  is  of  much  importance 
with  reference  both  to  our  prognosis  and  our  treatment,  for  we  should 
have  more  hope  of  the  recovery  of  a  child  whose  brain  is  merely  hyper- 
trophied,  than  of  one  whose  brain  is  distended  with  fluid,  while  the 
means  by  which  we  should  endeavour  to  effect  a  cure  would  differ  widely 
in  the  two  cases.  The  history  of  the  patient  would  afford  some  help 
towards  determining  this  question  ;  for  the  symptoms  of  chronic  hydroce- 
phalus generally  come  on  earlier,  and  soon  grow  much  more  serious,  than 
those  of  hypertrophy  of  the  brain,  and  the  cerebral  disturbance  is 
throughout  much  more  marked  in  cases  of  the  former  than  in  those  of 
the  latter  kind.  The  form  and  size  of  the  head,  too,  present  peculiarities 
by  which  you  may  often  be  enabled  to  distinguish  between  the  two 
conditions.  Both  diseases  are  attended  by  enlargement  of  the  head, 
and  in  both  the  ossification  of  the  skull  is  very  tardy,  but  the  head  does 
not  attain  so  large  a  size  in  hypertrophy  of  the  brain,  as  in  chronic  hy- 
drocephalus, neither  are  the  fontanelles  and  sutures  so  widely  open. 
The  skull,  likewise,  presents  some  peculiarities  in  form,  which  are  so  re- 
markable as  to  have  attracted  the  attention  of  several  observers,  though 

1  See  Mauthner's  elaborate  tables  of  the  weight  of  the  brain  under  various  circum- 
stances, lib.  cit.  sect.  v. 
*  Lib.  cit.  vol.  ii.  p.  771. 


TREATMENT   OP   HYPERTROPHY   OF   THE   BRAIN.  105 

I  must  own  that  I  do  not  thoroughly  understand  how  they  are  produced. 
The  head  not  merely  shews  no  tendency  to  assume  the  rounded  form 
characteristic  of  chronic  hydrocephalus,  but  its  enlargement  is  first 
apparent  at  the  occiput,  and  the  bulging  of  the  hind  head  continues 
throughout  especially  striking.  The  forehead  may,  in  the  course  of 
time,  become  prominent  and  overhanging,  but  the  eye  remains  deep  sunk 
in  its  socket,  for  no  change  takes  place  in  the  direction  of  the  orbitar 
plates  such  as  is  produced  by  the  pressure  of  fluid  within  the  brain  and 
which  gives  to  the  eye  that  unnatural  prominence,  and  that  peculiar 
downward  direction,  which  are  so  striking  in  cases  of  chronic  hydroce- 
phalus. In  hydrocephalus  the  anterior  fontanelle  is  tense  and  prominent, 
owing  to  the  pressure  of  the  fluid  within,  but  when  the  brain  is  hypertro- 
phied  there  is  no  prominence,  but  an  actual  depression  in  this  situation. 
I  have  more  than  once  observed  this  condition  in  a  very  remarkable 
degree,  the  depression  not  being  limited  to  the  anterior  fontanelle,  but 
being  observable  at  all  the  sutures ;  and  you  may  notice  something  of 
the  kind  in  this  cast. 

When  hypertrophy  of  the  brain  occurs  in  the  adult,  the  symptoms 
that  arise  are  in  great  measure  due  to  the  compression  which  the  organ 
undergoes  from  its  bony  case  being  too  small  to  contain  it.  These  symp- 
toms are  of  course  obscure,  while,  even  if  the  nature  of  the  affection 
could  be  recognised,  its  cure  must  be  hopeless.  In  the  infant,  however, 
and  the  child  whose  head  is  incompletely  ossified,  the  immediate  conse- 
quences of  the  evil  are  far  less  serious,  while  some  benefit  may  be 
expected  from  the  judicious  employment  of  remedies,  since  over-devel- 
opment of  the  brain  in  childhood  is  almost  always  associated  with 
general  disorder  of  the  process  of  growth  and  nutrition.  We  are  not, 
indeed,  acquainted  with  any  means  by  which  we  can  directly  check  the 
morbid  increase  of  the  brain,  but  all  our  efforts  should  be  turned  towards 
improving  the  general  health,  while  we  interfere  directly  with  the 
cerebral  symptoms  only  in  so  far  as  their  urgency  may  render  it  abso- 
lutely necessary.  The  child,  therefore,  must  not  be  dosed  with  calomel 
merely  because  its  head  is  affected,  though  the  deficient  secretion  of 
bile  may  often  render  the  employment  of  small  doses  of  mercurials 
necessary.  Similar  restrictions  would  apply  to  depletion,  for  we  have 
seen  that  the  hypertrophied  brain  is  characterised  by  want  of  blood 
rather  than  by  its  superabundance  ;  but  nevertheless,  occasional  attacks 
of  cerebral  congestion  may  render  local  depletion  necessary,  and  the 
exacerbations  of  headache,  with  vertigo  and  fever,  will,  if  severe,  be 
often  benefited  by  its  employment.  I  have  now  and  then  tried  counter- 
irritation  by  means  of  the  tartar  emetic  ointment  rubbed  into  the  back  of 
the  neck,  with  much  relief  to  the  head  symptoms,  in  the  case  of  children 
who  were  suffering  from  the  indications  of  hypertrophy  of  the  brain, 
but  I  should  fear  to  have  recourse  to  this  measure  in  infants.  In  them, 
indeed  one  of  our  first  efforts  must  be  to  relieve  the  brain  from  the 
constant  irritation  to  which  it  is  exposed  when  the  child  is  in  the  recum- 
bent posture,  and  the  head  rests  on  the  yielding  and  imperfectly  ossified 
occiput.  For  this  purpose  we  cannot  do  better  than  follow  the  sugges- 
tion of  a  German  physician,  Dr.  Elsasser,1  and  have  a  small  horsehair 
1  Der  weiche  Hinterkopf,  8vo.  p.  205.     Stuggart,  1843. 


106  TREATMENT  OF  HYPERTROPHY  OF  THE  BRAIN. 

cushion  prepared  for  the  child's  head  to  rest  on,  a  piece  being  cut  out 
of  it  large  enough  to  receive  the  occiput.  In  cases  both  of  hypertrophy 
of  the  brain  and  of  chronic  hydrocephalus,  I  have  seen  the  adoption  of 
this  simple  contrivance  followed  by  almost  immediate  cessation  of  the 
rotatory  movement  of  the  head,  and  by  quiet  sleep  in  its  cot,  to  which 
perhaps  for  weeks  before  the  child  had  been  a  stranger. 

It  is  not  desirable  that  a  child  who  suffers  from  this  affection  should 
sleep  entirely  without  covering  to  the  head.  The  profuse  perspiration 
of  the  head  is  more  effectually  checked  by  a  thin  linen  cap,  which  may 
be  changed  once  or  twice  in  the  night,  while  at  the  same  time  the  child 
is  saved  from  the  danger  of  catching  cold. 

While  these  hygienic  proceedings,  which  have  especial  reference  to 
the  head,  are  attended  to,  the  child  should  be  daily  sponged  with  salt 
and  water,  or  with  sea  water,  if  it  be  possible  to  remove  it  to  some  place 
on  the  coast,  such  as  Brighton ;  or  it  would  probably  be  benefited  by 
immersion  in  a  tan-bath,  in  which  it  should  remain  for  several  minutes. 

The  remedies  under  the  continued  use  of  which  I  have  seen  the  most 
good  result  are  the  extract  of  bark,  from  which  you  may  pass  to  the 
preparations  of  iron — such  as  Vinum  Ferri,  or  the  ferro-citrate  of 
quinine.2  I  have  not  made  much  trial  of  the  iodide  of  potassium,  since 
in  all  the  cases  that  I  have  seen  some  more  decided  tonic  appeared 
necessary.  I  have,  however,  given  the  syrup  of  the  iodide  of  iron  some- 
times with  advantage ;  and  in  cases  where  the  tendency  to  rickets  was 
well  marked,  I  have  observed  a  most  decided  improvement  follow  the 
use  of  the  cod-liver  oil,  in  doses  of  a  drachm  twice  a  day  for  a  child  of 
three  years  old.  I  may  just  mention  that,  notwithstanding  its  nauseous 
taste,  this  medicine  is  usually  readily  taken  by  children,  some  of  whom 
even  become  fond  of  it. 

With  reference  to  diet,  it  will  probably  be  desirable,  if  the  child  be 
not  weaned,  to  obtain  for  it  a  healthy  wet-nurse ;  while,  after  weaning, 
a  diet  of  milk,  with  an  egg  once  or  twice  daily,  will  often  agree  better 
than  any  other  food.  In  cases  of  this  kind,  and,  indeed,  in  all  where 
the  digestive  powers  are  feeble,  a  preponderance  of  farinaceous  food  is 
not  desirable,  while  the  child  may  with  safety  be  allowed  a  little  veal 
broth  or  beef-tea  daily,  or  even  a  little  meat  if  it  have  cut  some  of  its 
molar  teeth. 

Cases  of  'partial  hypertrophy  of  the  brain  are  on  record,  in  which  one 
hemisphere  alone  was  affected,  or  in  which  some  one  or  more  of  the 
central  parts  of  the  brain  greatly  exceeded  the  natural  size,  whilst  the 
rest  of  the  organ  deviated  in  no  respect  from  its  normal  condition.  An 
instance  of  the  kind  you  see  represented  in  this  drawing  of  Dr.  Mau- 
thner's,3  in  which  the  right  optic  thalamus  was  as  large  as  a  hen's  egg 
in  a  girl  of  three  years  old.     In  cases  of  this  sort  sometimes  no  symp- 

1  The  tan-bath,  which  I  have  employed  with  very  marked  benefit  in  the  case  of 
weakly  and  rickety  children  among  the  poor,  is  prepared,  as  directed  by  Dr.  Els'asser, 
by  boiling  three  handfuls  of  bruised  oak  bark,  tied  up  in  a  linen  bag,  in  three  quarts  of 
water  for  half  an  hour,  and  adding  the  jdecoction  to  the  water  of  the  child's  bath. 
These  baths  should  be  employed  tepid,  and  their  use  should  be  continued  every  day  for 
several  weeks. 

2  See  formulas  Nos.  3  and  4  at  pages  33  and  34. 

3  Lib.  cit.  plate  i.,  and  page  189. 


ATROPHY   OF   THE   BRAIN —  107 

toms  are  present,  and  the  anomaly  is  only  accidentally  discovered  after 
death ;  whilst  in  others,  although  there  are  indications  of  cerebral  dis- 
turbance, yet  they  are  not  such  as  to  enable  us  to  determine  the  nature 
of  the  evil  of  which  they  are  the  expression. 

There  is  a  condition  of  the  brain  the  direct  opposite  of  that  which  we 
have  been  examining,  in  which  the  organ  falls  below  the  natural  size, 
or  in  which  atrophy  of  the  train  exists.  I  do  not  refer  here  to  those 
cases  where  the  brain  is  imperfectly  formed/ the  head  exceedingly 
small,  and  the  child  idiotic  from  birth ;  but  this  state  of  microcephalus 
appears  sometimes  to  come  on  afterwards,  owing  probably,  as  has  been 
suggested,  to  premature  closure  of  the  fontanelles  and  sutures.  Such 
a  case  I  saw  several  years  ago,  when  a  woman  brought  to  me  her  boy, 
who  was  three  years  old,  the  elder  of  two  children  of  perfectly  healthy 
parents,  none  of  whose  relatives  had  ever  shown  any  sign  of  consump- 
tion, idiocy,  or  mental  derangement.  When  born,  this  boy  was  perfectly 
well  formed,  neither  did  he  present  any  peculiarity  till  he  was  six 
months  old,  when  his  mother  began  to  observe  that  he  did  not  look  any 
one  in  the  face,  and  that  he  seemed  to  take  but  little  notice  of  anything. 
When  eight  months  old,  he  began  to  have  fits,  which  had  since  returned 
about  once  a  week,  being  preceded  by  extreme  restlessness  for  a  day 
or  two.  The  fits  lasted  for  a  quarter  of  an  hour ;  they  were  attended 
by  convulsive  movements  of  both  sides,  and  followed  by  drowsiness,  which 
continued  for  some  days.  The  child  ate  and  drank,  though  not  heartily, 
and  he  never  seemed  anxious  for  food.  He  did  not  distinguish  between 
what  was  nice  and  what  was  nasty,  swallowing  all  things  with  the  same 
readiness,  though  deglutition  appeared  to  be  difficultly  performed.  He 
had  cut  all  his  teeth,  he  seemed  tolerably  well  nourished,  and  his  body 
and  limbs  were  well  formed.  He  was,  however,  quite  unable  to  stand ; 
he  passed  his  urine  and  faeces  under  him  without  appearing  to  take  the 
slightest  notice  of  it,  and  he  seemed  destitute  of  every  glimmering  of 
understanding.  His  mother  said  that  his  head  was  smaller  than  that 
of  her  infant  which  was  only  six  months  old.  It  measured  17  inches 
in  circumference  around  the  parietal  protuberances,  and  11  inches 
across  the  head  from  the  centre  of  the  meatus  of  one  ear  to  the  same 
point  on  the  opposite  side.  The  forehead  was  extremely  narrow,  and 
the  head  shelved  upwards  quite  in  a  sugar-loaf  shape.  All  the  sutures 
and  fontanelles  were  firmly  ossified,  but  I  have  unfortunately  omitted 
to  record  at  what  age  they  became  so.  I  never  saw  this  boy  again, 
but  two  or  three  similar  cases  have  since  come  under  my  notice.  I  have 
nothing  more  to  say  about  them,  for  their  cure  is  manifestly  quite 
hopeless,  and,  therefore,  though  they  may  interest  us  as  pathologists, 
they  scarcely  concern  us  as  practical  physicians. 

Of  much  higher  practical  importance  are  those  instances  in  which 
the  brain  of  children  ivastes  during  long-continued  illness.  The  scalp, 
in  such  cases,  will  usually  be  found  bloodless,  the  fontanelles  collapsed, 
and  the  process  of  ossification  will  be  seen  to  have  been  unusually  tardy. 
Fluid  will  be  found  within  the  sac  of  the  arachnoid,  and  effused  into 
the  subjacent  pia  mater.  The  brain  will  be  far  from  filling  up  the 
cavity  of  the  skull,  so  that  a  knife  may  be  passed  in  many  places 
between  it  and  the  cranial  walls.     The  sulci  between  the  convolutions 


108  AN   OCCASIONAL  RESULT   OF   CONTINUED   ILLNESS. 

appear  unusually  deep,  and  fluid  will  be  found  both  at  the  base  of  the 
brain  and  in  the  ventricles,  as  well  as  in  the  pia  mater.  The  cerebral 
substance  is  pale,  and  its  texture  firmer  than  usual. 

The  important  point  about  such  cases  is,  that  cerebral  symptoms  and 
frequently  recurring  convulsions  may  be  observed  in  a  child  whose  brain 
is  nevertheless  not  diseased,  but  too  feeble  and  too  wasted  to  perform 
its  functions.  If,  then,  you  find  indications  of  cerebral  disturbance 
come  on  in  infants  who  have  been  exhausted  and  emaciated  by  previous 
illness,  you  must  not  interpose  too  hastily  with  remedies  directed  against 
a  supposed  disease  of  the  brain,  but  bethink  you  whether  these  symp- 
toms may  not  be  merely  the  signs  of  the  brain  having  become  unequal 
to  its  duties  from  its  having  been  imperfectly  nourished :  and  do  not, 
without  consideration,  abandon  the  tonic  plan  of  treatment  which  you 
had  been  previously  pursuing. 

It  is  only  in  infants  that  accidents  of  this  grave  nature  are  likely  to 
ensue,  from  the  imperfect  nutrition  of  the  brain  consequent  on  pro- 
tracted illness ;  but  symptoms  arise  in  older  children,  under  similar 
circumstances,  well  calculated  to  excite  the  apprehension  of  parents. 
In  children  who  have  but  lately  learned  to  talk,  I  have  sometimes  known 
loss  of  speech  follow  a  long  illness,  the  child  being  too  weak  to  talk, 
just  for  the  same  reason  as  it  is  too  weak  to  walk.  Occasionally,  how- 
ever, the  child  apparently  regains  its  previous  health,  and  yet  makes 
no  efforts  to  articulate,  even  for  two  or  three  months.  In  cases  of  this 
kind  I  have  seen  parents  thrown  into  great  anxiety  from  the  fear  lest  the 
child's  continued  silence  should  be  the  result  of  the  intellect  having 
become  impaired  during  its  illness.  I  imagine  that  in  many  of  these 
cases  the  child  has  forgotten  during  its  illness  much  of  its  newly- 
acquired  knowledge,  and  that  it  is  some  time  before  it  again  feels  equal 
to  the  mental  effort  of  shaping  its  ideas  into  words.  Usually,  however, 
when  it  begins  to  make  the  effort,  it  recovers  its  speech  rapidly ;  and 
you  may  therefore  console  the  parents  with  this  prospect. 

Even  a  manifest  retrocession  of  the  intellectual  endowments  should 
not  be  regarded  with  too  much  anxiety,  when  it  has  followed  some  long- 
continued  disease,  for  it  may  be  the  result  of  mere  weakness ;  the  vacant 
look,  the  unmeaning  laugh,  and  the  silly  manner,  gradually  disappear- 
ing as  the  child  gains  strength.  The  brain  seems  to  regain  its  lower 
powers,  and  to  perform  its  humbler  functions,  before  it  resumes  its 
nobler  office  as  the  organ  of  the  mind. 

Partial  Atrophy,  like  partial  hypertrophy  of  the  brain,  may  occur 
we  know  not  why,  and  may  be  discovered,  after  death,  where  the  exis- 
tence of  cerebral  disease  had  never  been  suspected ;  or  we  may  find  the 
explanation  of  a  number  of  anomalous  symptoms  which  had  existed 
during  life,  in  a  wasted  condition  of  some  portion  of  the  organ.  This 
state  may  be  the  result  of  original  conformation,  or  it  may  come  on  as 
the  result  of  disease,  in  which  latter  case  the  substance  of  the  wasted 
portion  of  the  brain  is  usually  found  to  be  much  firmer  than  natural. 
We  are  greatly  in  the  dark  as  to  the  nature  of  the  process  by  which 
this  change  is  effected ;  but  it  is  thought  in  some  cases  to  be  the  remote 
consequence  of  haemorrhage  into  the  cerebral  substance,  and  in  others, 
to  be  induced  by  a  slow  kind  of  inflammation.     One  case  of  this  kind 


PARTIAL  ATROPHY  OP  THE  BRAIN.  109 

has  come  under  my  own  notice,  which,  for  its  rarity,  I  will  relate  to 
you. 

The  patient  was  a  little  girl,  aged  3  years  and  10  months,  the  child 
of  phthisieal  parents,  but  whose  health,  though  delicate,  had  never  been 
interrupted  by  any  serious  illness  until  she  had  an  attack  of  remittent 
fever  in  the  early  part  of  the  spring  of  1845  :  she  recovered  from  it  with- 
out any  bad  symptom,  and  seemed  doing  pretty  well  for  about  a  month, 
when  she  became  sleepy  and  heavy,  and  feverish,  for  which  symptoms 
she  was  brought  to  me  on  May  19th.     After  being  under  a  mild  anti- 
phlogistic treatment  for  a  week,  she  got  better,  and  was  beginning  to 
walk  about  again,  when  she  awoke  one  morning  with  her  face  drawn  to 
one  side, — a  condition,  however,  which  did  not  continue.    When  she  at- 
tempted to  walk,  it  was  noticed  that  she  halted  very  much  on  her  left  leg, 
and  that  it  sometimes  gave  way  under  her,  so  that  she  fell  down  on 
that  side,  and  then  turned  round  upon  her  back.     She  had,  besides, 
but  little  power  with  her  left  hand  and  arm,  so  that  she  could  not  grasp 
any  thing  firmly,  nor  hold  it  steadily.     The  child's  bowels  were  at  that 
time  constipated :  I  purged  her  freely  and  sent  her  into  the  country, 
when  she  returned  in  the  beginning  of  August,  much  improved  in  every 
respect,  though  still  limping  a  little  with  the  left  leg,  and  using  her 
right  arm  in  preference  to  the  left.     At  the  end  of  September  I  saw 
her  again,  she  having  then  a  bad  impetiginous  eruption  on  the  scalp, 
which  was  treated  with  warm  poultices  and  water  dressing ;  when,  on 
October  6th,  she  began  to  limp  with  her  right  leg,  just  as  she  had  pre- 
viously done  with  her  left ;  though  in  other  respects  she    continued 
pretty  well.     On  October  17th,  the  affection  of  the  right  leg  was  a  good 
deal  less  marked ;  but  the  child  now  became  unwilling  to  walk,  often 
turning  giddy,  and  always  catching  hold  of  something   by  which  to 
steady  herself.     When  attempting  to  walk,  she  often  fell  down  into  a 
sitting  posture ;  and  then  would  sit  on  the  floor,  laughing  loudly.     Fits 
of  uncontrollable  laughter  often  came  on  without  any  cause,  and  the 
face  began  to  assume  an  idiotic  expression.     There  was  occasionally 
slight  inward  strabismus  with  both  eyes,  but  the  pulse  was  soft  and 
undisturbed ;  the  bowels  were  regular,  and  the  evacuations  natural,  and 
the  child  rested  well  at  night,  though  her  head  was  often  rather  hot. 
A  week  afterwards  there  was  no  new  symptom,  except  that  the  child 
kept  her  neck  quite  stiff,  as  though  she  feared  to  move  it.     Her  head 
grew  hotter,  and  she  began  to  have  a  frequent  teasing  cough,  while  her 
power  of  walking  varied  almost  every  day ;  she  now,  too,  grew  more 
restless  at  night.     On  the  morning  of  the  27th,  frequent  convulsive 
twitches  of  the  muscles  of  the  face  and  extremities  came  on,  and  the 
left  eye  became  permanently  turned  inwards.     She  had  no  sleep  in  the 
night ;  general  convulsions  came  on  at  8  A.  M.  on  the  28th,  and  she 
died  convulsed  two  hours  afterwards. 

I  found  some  deposit  of  tubercle  in  the  bronchial  glands,  but  none  in 
the  brain,  where  I  had  expected  to  discover  it.  The  left  hemisphere  of 
the  cerebellum,  however,  was,  as  you  see  both  in  this  drawing  and  in 
the  other  preparation  itself,  fully  a  third  smaller  than  the  right ;  it  was  of 
extremely  firm  consistence,  quite  leathery,  and  on  making  a  section  of 
it,  its  surface  presented  arose  tint.    The  halves  of  the  pons  and  medulla 


110  PARTIAL  ATROPHY  OP  THE  BRAIN. 

oblongata  were  of  equal  size,  as  were  the  two  hemispheres  of  the  cere- 
brum. It  was  evident,  too,  that  this  condition  was  not  congenital,  since 
the  two  halves  of  the  skull  were  of  equal  size,  and  the  elevations  and 
depressions  in  the  interior  of  its  base  were  precisely  similar  on  both 
sides.  There  was  a  little  fluid  at  the  base  of  the  brain,  but  none  in  the 
ventricles ;  a  state  of  general  congestion  of  the  brain  and  its  mem- 
branes being  the  only  other  remarkable  appearances. 

The  spinal  cord  could  not  be  examined. 

There  was  no  trace  of  any  old  effusion  of  blood  in  the  substance  of 
the  cerebellum,  though  the  symptoms  that  occurred  in  May,  and  the 
subsequent  gradual  improvement  of  the  patient,  are  not  easily  expli- 
cable on  any  other  supposition  than  that  the  haemorrhage  had  at  that 
time  taken  place  into  the  substance  of  the  brain.  The  history  of  the 
case  presents  another  difficulty,  in  the  circumstance  that  the  disease 
was  seated  on  the  same  side  as  that  to  which  the  symptoms  had  been 
chiefly  referred.  Another  problem  which  I  cannot  pretend  to  solve  is, 
why  the  paralysis  should  in  the  first  instance  have  affected  the  left  side, 
while,  on  the  recurrence  of  the  relapse  in  October,  the  right  leg  was 
palsied.  I  must  therefore  content  myself  with  the  bare  relation  of  this 
history. 


LECTUEE     X. 

Hydrocephaloid  Disease — often  succeeds  to  sympathetic  disturbance  of  brain  in  course 
of  various  affections — supervening  on  diarrhoea,  pneumonia,  and  cerebral  congestion 
— diagnosis  under  elich  of  these  circumstances. — Prophylaxis,  and  treatment. 

Tubercle  of  the  Brain — its  frequency  in  childhood — its  anatomical  characters — 
symptoms — occasionally  absent — generally  very  obscure — diversities  in  this  respect 
cannot  be  explained  by  the  morbid  appearances. — Occasional  recovery  where 
symptoms  of  cerebral  tubercle  have  long  existed. — Treatment. 

Hydatids  and  Cancer  of  the  brain. 

Closely  connected  with  the  state  of  atrophy  of  the  brain,  which  we 
examined  in  the  last  lecture,  is  that  condition  which  is  induced  if  the 
organ  be  somewhat  suddenly  deprived  of  its  usual  supply  of  blood. 
Even  in  the  adult  a  profuse  loss  of  blood  is  followed,  as  you  well  know, 
by  extremely  severe  headache,  and  by  various  other  cerebral  symptoms. 
In  the  child,  whose  brain  needs  for  the  due  performance  of  its  functions 
a  proportionably  larger  quantity  of  blood,  the  symptoms  that  follow  its 
excessive  loss  are  of  a  corresponding  gravity.  Often,  indeed,  they 
present  a  striking  similarity  to  those  which  betoken  inflammation  of 
the  brain  ;  a  fact  implied  in  the  name  of  the  hydrocephaloid  disease,  by 
which  Dr.  Marshall  Hall,  who  was  among  the  first  to  call  the  notice 
of  the  profession  to  this  affection,  has  proposed  that  it  should  be 
designated. 

"  This  affection,"  says  he,  in  his  admirable  essay  on  the  subject,1 

1  Republished  in  his  work  On  the  Diseases  and  Derangement  of  the  Nervous  System, 
8vo.  chap.  v.  sect,  iii.,  London,  1841.  It  can  scarcely  be  necessary  to  refer  to  Dr. 
Gooch's  paper  "On  Symptoms  in  Children  erroneously  attributed  to  Congestion  of  the 
Brain,"  for  another  most  graphic  account  of  this  disorder. 


HYDROCEPHALOID   DISEASE.  Ill 

"  may  be  divided  into  two  stages  :  the  first,  that  of  irritability  ;  the 
second,  that  of  torpor.  In  the  former  there  appears  to  be  a  feeble 
attempt  at  reaction ;  in  the  latter,  the  powers  appear  to  be  more  pros- 
trate. These  two  stages  resemble  in  many  of  their  symptoms  the  first 
and  second  stages  of  hydrocephalus  respectively. 

"  In  the  first  stage  the  infant  becomes  irritable,  restless  and  feverish  ; 
the  face  flushed,  the  surface  hot,  and  the  pulse  frequent ;  there  is  an 
undue  sensitiveness  of  the  nerves  of  feeling,  and  the  little  patient  starts 
on  being  touched,  or  from  any  sudden  noise  ;  there  are  sighing  and 
moaning  during  sleep,  and  screaming;  the  bowels  are  flatulent  and 
loose,  and  the  evacuations  are  mucous  and  disordered. 

"  If,  through  an  erroneous  notion  as  to  the  nature  of  this  affection, 
nourishment  and  cordials  be  not  given,  or  if  the  diarrhoea  continue, 
either  spontaneously,  or  from  the  administration  of  medicine,  the 
exhaustion  which  ensues  is  apt  to  lead  to  a  very  different  train  of 
symptoms.  The  countenance  becomes  pale,  and  the  cheeks  cool  or 
cold ;  the  eyelids  are  half  closed ;  the  eyes  are  unfixed,  and  unattracted 
by  any  object  placed  before  them,  the  pupils  unmoved  on  the  approach 
of  light ;  the  breathing,  from  being  quick,  becomes  irregular,  and 
affected  by  sighs*;  the  voice  becomes  husky  ;  and  there  is  sometimes  a 
husky,  teasing  cough ,  and  eventually,  if  the  strength  of  the  little 
patient  continue  to  decline,  there  is  a  crepitus  or  rattling  in  the 
breathing.  The  evacuations  are  usually  green  ;  the  feet  are  apt  to  be 
cold." 

In  early  infancy  symptoms  of  this  kind  sometimes  succeed  to  prema- 
ture weaning,  especially  if  that  be  followed  by  an  unsuitable  diet ;  but 
afterwards  they  generally  succeed  to  some  definite  attack  of  illness, 
either  exhausting  in  itself,  or  for  the  cure  of  which  active  measures  had 
been  necessary.  It  is  important,  too,  to  bear  in  mind  that  they  are 
not  equally  apt  to  come  on  in  the  course  of  all  diseases,  but  that  those 
in  the  early  stages  of  which  considerable  cerebral  irritation  has  existed, 
are  much  more  likely  to  assume  the  characters  of  this  spurious  hydro- 
cephalus when  the  bodily  powers'  are  exhausted. 

There  is  no  disorder  in  which  the  two  conditions  of  considerable 
sympathetic  disturbance  of  the  brain,  coupled  with  rapid  exhaustion  of 
the  vital  powers,  are  so  completely  fulfilled  as  in  infantile  diarrhoea, 
and  in  no  other  affection  do  we  meet  with  such  frequent  or  such  well- 
marked  instances  of  the  supervention  of  the  hydrocephaloid  disease. 

It  is  not  long  since'  a  previously  healthy  boy,  aged  18  months,  was 
brought  to  me  suffering  from  vomiting  and  diarrhoea,  which  had  existed 
for  three  days  previously.  After  treatment  had  been  continued  for  two 
days  the  purging  ceased,  but  the  child  seemed  to  have  a  distaste  for  all 
nourishment,  and  refused  both  milk  and  arrow-root,  and  the  mother 
made  but  few  attempts  to  overcome  this  repugnance ;  so  that  for 
twenty-four  hours  the  child  took  hardly  anything  except  water  and 
barley-water,  and  those  in  small  quantities.  On  the  afternoon  of  the 
sixth  day  the  child  became  faint,  and  seemed  so  feeble  during  the  night 
that  the  mother  became  much  alarmed,  and  came  again  to  me  on  the 
morning  of  the  seventh  day.  The  child's  face  was  then  sunken  and 
very  anxious ;  it  lay,  as  if  dozing,  with  half-closed  eyes ;   breathing 


112  SYMPTOMS   OF   HYDRO CEPHALOID   DISEASE. 

hurriedly  ;  suddenly  waking  up  from  time  to  time  in  a  state  of  alarm 
and  restlessness,  and  then  in  a  few  moments  subsiding  into  its  former 
condition.  The  skin  was  dry  but  cool ;  the  extremities  were  almost 
cold  ;  the  lips  were  dry  and  parched,  and  some  sordes  had  collected 
about  the  teeth  ;  the  tongue  was  dry,  red,  and  glazed,  and  coated  in 
the  centre  and  towards  the  root  with  yellowish  fur.  The  pulse  was 
extremely  feeble.  There  was  very  great  thirst.  The  bowels  had  not 
acted  for  twelve  hours. 

I  ordered  the  child  a  table-spoonful  of  equal  parts  of  milk  and  barley 
water  every  half  hour,  with  the  addition  of  fifteen  drops  of  brandy  every 
hour,  and  directed  that  some  strong  veal  broth  should  be  prepared  and 
given  every  two  hours.  At  the  same  time,  a  draught  containing  ten 
grains  of  aromatic  confection,  half  a  drachm  of  the  compound  tincture 
of  bark,  and  six  drops  of  sal  volatile,  was  given  every  three  hours,  and 
a  grain  of  Dover's  powder  was  directed  to  be  taken  at  bed-time. 

Within  six  hours  after  the  commencement  of  this  treatment  the  child 
began  to  improve ;  it  slept  tolerably  well  in  the  night,  and  the  next  day 
was  lying  tranquilly  in  bed,  looking  about  and  smiling  cheerfully ;  the 
extremities  were  warmer,  and  the  skin  had  lost  its  harshness ;  the  tongue 
was  no  longer  dry,  and  the  pulse  had  increased  in  power.  The  stimu- 
lants were  gradually  withdrawn ;  no  further  bad  symptoms  came  on,  and 
the  child  was  soon  convalescent. 

It  is  of  great  importance  rightly  to  interpret  the  meaning  of  the 
symptoms  which  attend  the  first  stage  of  this  affection,  and  to  discrimi- 
nate between  the  cerebral  disturbance  of  approaching  exhaustion,  and 
that  which  implies  the  existence  of  real  mischief  in  the  brain. 

A  little  girl  was  seized  with  diarrhoea  on  August  8th,  which  at  first 
was  severe  but  soon  yielded  to  treatment,  and  she  was  again  conva- 
lescent; when,  on  the  15th,  vomiting  and  purging  returned  with  great 
violence,  and  were  attended  with  much  febrile  disturbance.  On  the 
following  day  she  was  still  worse  in  all  respects,  but  was  not  brought  to 
me  again  until  the  17th.  She  then  looked  exceedingly  ill ;  her  face  was 
sallow,  but  with  a  flush  on  each  cheek,  and  her  eyes  were  deeply  sunk. 
She  lay  in  a  half  dozing  state,  with  her  eyelids  half  closed,  and  the  eye- 
balls turned  upwards,  so  that  nothing  but  the  sclerotica  was  visible ;  but 
from  this  condition  she  awoke  frequently  and  suddenly  in  a  state  of  great 
alarm,  and  looking  as  if  she  were  about  to  have  a  fit  of  convulsions. 
Her  skin  was  hot  and  very  dry ;  her  pulse  very  frequent,  but  not  strong ; 
and  there  was  some  subsultus  of  the  tendons  of  the  wrist.  The  abdomen 
was  rather  tympanitic ;  the  tongue  red,  coated  with  white  mucus  ;  the 
thirst  was  great,  the  vomiting  very  frequent,  and  the  bowels  acted  two 
or  three  times  in  the  course  of  an  hour,  the  evacuations  having  the 
appearance  of  dirty  water. 

The  child  was  immediately  placed  in  a  tepid  bath ;  an  enema  con- 
taining five  drops  of  laudanum  was  next  administered,  and  the  abdomen 
was  covered  with  a  large  bran  poultice.  The  extreme  irritability  was 
almost  immediately  relieved  by  the  warm  bath,  and  still  further  soothed 
by  the  enema.  The  bowels  ceased  to  act  so  frequently,  and  the  stomach 
began  to  bear  small  quantities  of  barley  water  and  other  drinks,  which 
were  given  cold.  In  a  few  hours  the  imminent  danger  had  passed  away, 
and  the  child  recovered  in  the  course  of  a  few  days. 


SYMPTOMS   OF   HYDROCEPHALOID  DISEASE.  113 

If,  in  a  case  of  this  kind,  you  fall  into  the  error  of  regarding  the 
cerebral  symptoms  as  the  signs  of  active  disease,  and  withhold  the 
Dover's  powder,  or  the  opiate  enema  that  might  have  checked  the 
diarrhoea  and  soothed  the  irritability,  while  you  apply  cold  lotions  to 
the  head  and  give  the  child  nothing  more  nutritious  than  barley  water 
in  small  quantities,  because  the  irritability  of  the  stomach  which  results 
from  weakness  seems  to  you  to  be  the  indication  of  disease  in  the  brain, 
the  restlessness  will  before  long  alternate  with  coma,  and  the  child  will 
die  either  comatose  or  in  convulsions. 

But  it  is  not  only  in  the  course  of  diarrhoea  that  errors  of  this  sort 
may  be  committed.  The  early  stages  of  pneumonia  are  often  attended 
with  so  much  sympathetic  disturbance  of  the  brain,  as  to  throw  the  other 
symptoms  into  the  background.  The  child  vomits,  it  refers  all  its  suf- 
fering to  its  head,  and  possibly  has  an  attack  of  convulsions  almost  at 
the  outset.  You  not  unnaturally  assume  the  case  to  be  one  of  cerebral 
congestion,  and  treat  it  accordingly  with  free  local  depletion.  On  the 
next  day  the  indications  of  disordered  respiration  are  more  apparent; 
you  think  your  former  diagnosis  was  incorrect,  and  probably  apply  more 
leeches  to  the  chest  to  combat  the  pneumonia  you  had  overlooked.  The 
urgency  of  the  symptoms  may  be  relieved  by  these  means,  or,  if  that  be 
not  the  case,  still  the  reaction  will  diminish  with  the  diminished  power, 
and  the  child  for  a  short  time  seems  to  suffer  less.  But  soon  the  rest- 
lessness of  exhaustion  comes  on,  and  then  follow  the  soporose  condition 
and  the  apparent  coma ;  you  condemn  yourself  for  having  overlooked  the 
cerebral  mischief,  of  which  you  fancy  you  now  have  most  convincing 
proof;  you  renew  your  antiphlogistic  measures,  to  arrest,  if  it  be  not 
too  late,  this  imaginary  hydrocephalus,  and  your  patient  dies. 

Something  of  the  same  kind,  too,  may  happen  in  cases  where  the 
brain  has  really  been  congested,  and  where  the  depletion,  which  you 
practised  somewhat  too  freely,  was  in  reality  indicated,  though  to  a 
smaller  amount.  The  restlessness  and  heat  of  head  may  have  been 
diminished  by  your  treatment,  and  the  bowels  may  have  been  relieved 
by  the  purgatives  you  administered.  In  a  few  hours,  however,  rest- 
lessness returns,  though  not  to  so  great  a  degree  as  before,  the  child 
moans  sadly  when  awake,  and  this  suffering  state  alternates  with  a 
drowsy  condition,  while  the  stomach,  irritable  before,  now  rejects  every 
thing  almost  as  soon  as  shallowed,  though  the  child  still  seems  eager 
for  drink.  The  previous  arrest  of  very  similar  symptoms,  though  but 
for  a  few  hours,  by  active  treatment,  seems  to  you  to  indicate  the  pro- 
priety of  continuing  the  same  plan,  but  nevertheless,  the  drowsiness 
deepens  into  coma,  and  the  child  dies,  of  hydrocephalus,  as  you  sup- 
pose,— in  reality  of  the  nimia  eura  medici. 

"  Forewarned,  forearmed,"  says  the  old  proverb.  When  head  symp- 
toms come  on  in  the  infant,  do  not  judge  of  their  import  simply  from 
the  present  condition  of  the  child,  but  ascertain  its  previous  history. 
Learn  whether  any  other  members  of  the  family  have  had  hydrocephalus 
or  been  consumptive.  Inquire  whether  this  infant  has  thriven  at  the 
breast,  or  whether  it  has  for  some  time  been  drooping ;  if  already 
weaned,  ascertain  on  what  it  is  now  fed,  whether  signs  of  declining 
health  soon  followed  on  the  change  of  diet,  while  it  throve  so  long  as 


114  DIAGNOSIS   FROM   ACTIVE   CEREBRAL   DISEASE. 

it  was  suckled.  Ask  what  signs  of  disorder  of  the  bowels  there  have 
been,  and  observe  at  what  times  the  vomiting  comes  on ;  whether  only 
after  sucking,  or  taking  food,  or  whether  efforts  to  vomit  occur  when 
the  stomach  is  quite  empty. 

In  a  case  where  the  symptoms  of  cerebral  disturbance,  and  those  of 
disordered  respiration,  come  on  almost  at  the  same  time  in  a  previously 
healthy  child,  and  so  alternate  with  each  other  as  to  render  your 
diagnosis  difficult,  you  will  do  well  to  remember  that  pneumonia  often 
sets  in  with  much  sympathetic  disorder  of  the  nervous  system,  and 
that  the  disease  is  much  more  likely  to  be  seated  in  the  lungs  than  in 
tha  brain.  In  most  cases  auscultation  will  enable  you  to  decide  the 
question,  and  if  you  once  accustom  yourselves  to  listen  to  a  child's 
chest  as  invariably  as  you  would  look  at  its  tongue  or  count  its  pulse, 
you  will  but  seldom  have  to  reproach  yourself  for  the  uncertain  diag- 
nosis and  the  vacillating  treatment  into  which,  in  cases  of  this  descrip- 
tion, you  will  otherwise  be  too  often  betrayed. 

In  a  child  suffering  from  diarrhoea,  you  will  be  prepared  to  meet 
with  sympathetic  disturbance  of  the  brain,  and  will  not  allow  the  occur- 
rence of  its  symptoms  to  deter  you  from  adopting  the  treatment  which 
the  diarrhoea  requires.  If  doubts  cross  your  mind  as  to  their  signifi- 
cation, and  you  fear  lest  mischief  be  really  going  on  in  the  brain,  it 
will  usually  suffice  to  watch  the  symptoms  closely,  in  order  to  detect  a 
want  of  correspondence  between  them,  which  would  not  exist  if  true 
cerebral  disease  were  present.  Attention  to  this  point  will  guard  you 
from  error  during  the  stage  of  excitement,  as  well  as  in  that  of  exhaus- 
tion and  stupor,  which  simulates  the  last  stage  of  hydrocephalus. 

Under  no  circumstances  are  mistakes  more  easily  committed,  and 
never  are  their  results  more  mischievous,  than  when  real  congestion  of 
the  brain  has  been  somewhat  over-treated,  and  the  consequent  symp- 
toms of  exhaustion  are  supposed  to  be  those  of  advancing  disease.  In 
such  a  case,  however,  it  would  usually  be  observed  that  great  faintness 
had  been  induced  by  the  first  depletion,  and  that  the  quiet  which  suc- 
ceeded it  was  that  of  exhaustion  as  much  as  of  mitigated  suffering.  If 
so,  the  returning  restlessness  would  probably  be  the  index  of  the  feeble 
power  of  the  brain,  no  longer  adequate  to  the  performance  of  its  wonted 
functions,  rather  than  the  evidence  of  active  disease  of  the  organ.  Nor 
would  the  history  be  the  only  safeguard  from  error,  but  the  fontanelle 
sunk  below  the  level  of  the  cranial  bones,  instead  of  being  tense  and 
pulsating,  the  cool  surface,  and  the  pulse  presenting  no  other  characters 
than  those  of  frequency  and  feebleness,  would  all  point  to  the  real  nature 
of  the  case.  You  do  not  need  to  be  told  that  to  deplete  under  such 
circumstances  would  be  to  destroy  your  patient — that  food  is  needed, 
not  physic.  The  sunken  powers  of  life  are  to  be  rallied,  and  as  their 
strength  returns,  the  functions  of  the  brain  will  again  go  on  harmo- 
niously. 

Although  the  diagnosis  of  this  affection  is  sometimes  attended  with 
difficulty,  the  rules  for  its  prevention  and  its  cure  are  happily  very 
simple.  Bearing  in  mind  the  possible  supervention  of  the  hydrocephaloid 
disease,  you  would  never  keep  an  infant  from  the  breast  nor  put  a 
young  child  on  a  spare  diet  for  several  days,  without  most  absolute 


TREATMENT  OF  THE  AFFECTION.  115 

necessity ;  you  would  pay  especial  attention  to  its  food,  if  the  diseases 
from  which  it  suffers  be,  like  diarrhoea,  such  as  interfere  directly  with 
its  nutrition.  Again,  you  would  not  trust  depletion  of  a  young  child, 
especially  if  suffering  from  head  affection,  to  a  nurse,  but  would  your- 
selves exercise  the  supervision  of  it.  And,  lastly,  in  the  treatment  of 
every  disease  you  would  at  once  suspend  the  antiphlogistic  measures 
that  you  had  previously  been  adopting,  and  resort  to  the  use  of  stimu- 
lants and  tonics  so  soon  as  any  of  the  symptoms  that  we  have  been 
examining  make  their  appearance. 

The  state  of  general  restlessness  and  irritability  that  attends  the 
early  stages  of  exhaustion  is  often  greatly  soothed  by  the  tepid  bath, 
continued  for  not  more  than  five  minutes,  for  fear  of  still  further 
depressing  the  infant's  powers.  While  you  secure  a  free  access  of  air, 
too,  you  must  be  extremely  cautious  to  maintain  the  room  at  a  sufficient 
temperature;  for  the  power  of  generating  heat  is  diminished  in 
a  very  remarkable  degree  in  young  animals  who  from  any  cause  are 
insufficiently  nourished.  The  irritability  of  the  stomach  is  best  over- 
come by  giving  nourishment  in  extremely  small  quantities, — as  a  dessert- 
spoonful of  asses'  milk  for  an  infant,  or  of  veal-tea  for  an  older  child, 
given  by  little  and  little  every  half  hour.  If  the  symptoms  have  suc- 
ceeded to  weaning,  a  healthy  wet-nurse  should,  if  possible,  be  at  once 
obtained ;  but  as  the  effort  to  suck  seems  sometimes  to  exhaust  the 
child,  and,  probably  thereby  to  favour  vomiting,  it  is  sometimes  better 
at  first  to  give  the  nurse's  milk  by  a  tea-spoon.  If  the  exhaustion  be 
very  great,  and  a  state  analogous  to  coma  be  impending,  a  hot  mustard 
bath  is  sometimes  serviceable  in  rousing  the  child ;  while,  at  the  same 
time,  a  few  drops  of  sal  volatile,  or  of  brandy,  may  be  given  every  few 
hours.  It  is  desirable,  however,  to  suspend  the  use  of  the  more  powerful 
direct  stimulants  so  soon  as  it  can  safely  be  done,  though  a  nutritious 
diet  will  be  necessary  for  some  time.  Tonic  medicines,  likewise,  are 
often  of  much  service,  few  of  which  are  preferable  to  the  extract  of 
bark,  which,  dissolved  in  carraway  water,  mixed  with  a  few  drops  of  the 
tincture,  and  well  sweetened,  will  be  taken  very  readily  by  most  children. 
The  addition  of  a  little  milk  to  the  medicine  when  taken  still  further 
covers  any  unpleasant  taste.1 

Those  cases  in  which  the  brain  becomes  the  seat  of  various  morbid 
growths  still  remain  for  us  to  consider,  before  we  pass  to  the  study  of 
affections  of  the  spinal  cord, 

In  the  child,  as  in  the  adult,  the  brain  may  become  the  seat  of  hydatid 
cysts,  or  of  cancerous  tumours,  or  of  tubercular  deposits  ;  but  I  should 
not  detain  you  long  with  their  study,  if  it  were  not  that  the  last  of  these 
three  morbid  conditions,  though  exceedingly  rare  in  the  adult,  is  by  no 
means  unusual  in  the  child.  Thus,  while  M.  Louis  met  with  only  a 
single  case  in  which  the  brain  contained  tubercle,  out  of  117  examina- 
tions of  adults  who  had  died  of  phthisis,  MM.  Rilliet  and  Barthez 
discovered  tubercle  in  the  brain  of  37  out  of  312  children,  between  the 
ages  of  1  and  15,  in  some  organ  or  other  of  whose  body  this  morbid 
deposit  existed.     You  will  remember  that  I  am  not  now  speaking  of 

1  See  Formula  No.  3,  at  page  33. 


116  TUBERCLE  OF  THE  BRAIN. 

cases  where  tubercle  is  present  merely  in  the  membranes  of  the  brain, 
producing  that  granular  appearance  to  which  I  called  your  attention 
when  treating  of  acute  hydrocephalus  ;  but  my  remarks  refer  to  separate 
deposits  of  tubercular  matter  in  the  substance  of  the  brain.  These 
deposits  are  for  the  most  part  distinctly  circumscribed,  of  a  rounded 
form,  and  varying  in  dimensions  from  the  size  of  a  millet-seed  to  that 
of  a  split  pea,  or  of  a  bean,  or  even  larger.  The  largest  mass  that  I 
ever  met  with  in  the  brain  of  a  child  was  almost  as  big  as  a  sugared 
almond,  but  they  have  been  seen  three  or  four  times  as  large.  Some- 
times there  is  but  a  single  deposit  in  the  brain,  but  in  the  majority  of 
cases  there  are  three  or  four  small  deposits,  of  the  size  of  a  millet-seed, 
or  rather  larger,  as  well  as  a  single  mass  of  great  magnitude.  Some- 
times, though  not  often,  the  deposits  of  tubercle  are  limited  to  one 
hemisphere  of  the  brain;  but  it  generally  happens  that  there  is  a 
marked  preponderance  of  the  affection  on  one  side.  The  situation  of 
these  deposits  varies  greatly,  and  they  have  been  found  in  all  parts  of 
the  brain,  both  on  its  surface  and  in  its  interior.  The  smaller  deposits 
are,  I  think,  most  frequently  observed  on  the  convexity  of  the  brain, 
and  they  are  then  found  closely  adherent  to  the  pia  mater,  to  which 
they  remain  attached  if  that  membrane  be  stripped  off.  They  seem, 
however,  to  have  some  connection  with  the  cerebral  substance  besides 
mere  juxta-position,  since  a  thin  investment  of  it  clings  to  them,  and 
the  place  where  they  were  situated  may  be  seen  after  their  removal  to 
be  quite  uneven.  Even  when  situated  at  the  base  of  the  brain,  or  in 
the  cerebellum,  they  often  retain  this  relation  to  the  pia  mater ;  and 
those  larger  masses,  which  generally  appear  more  deeply  seated,  will 
often  be  found,  if  the  convolutions  be  unfolded,  to  have  been  in  reality 
not  far  removed  from  the  surface.  Now  and  then  a  distinct,  firm, 
fibrous  capsule  may  be  found  investing  the  deposit;  but  this  is  oftener 
absent,  or  at  any  rate  so  delicate  as  not  to  be  clearly  perceptible.  I 
have  never  seen  these  deposits  presenting  throughout  the  characters  of 
the  grey  semi-transparent  tubercle  frequently  noticed  in  the  lungs,  but 
once  I  found  the  exterior  of  a  small  deposit  in  this  stage,  while  its  cen- 
tral part  had  undergone  the  transformation  into  the  ordinary  friable 
yellow  tuberculous  matter, — a  condition  which  Rokitansky  has  also  occa- 
sionally met  with.  Softening  sometimes  goes  on  in  cerebral  tubercles ; 
the  process  beginning  in  the  centre,  and  gradually  extending  towards 
the  periphery, — a  condition  which  I  have  observed  in  3  out  of  14  cases. 
The  brain  around  the  softened  deposit  is  almost  always  of  a  rose  tint, 
and  more  or  less  softened,  though  this  alteration  seldom  extends  for  a 
distance  of  more  than  two  or  three  lines  ;  and  once  I  observed  the  cere- 
bral substance  perfectly  unchanged  around  a  small  tubercle,  in  which 
the  process  of  softening  was  already  considerably  advanced.  As  a 
general  rule,  the  brain  around  deposits  of  crude  tubercle  still  retains  its 
natural  characters ;  but  to  this  I  have  seen  one  exception. 

If  death  usually  occurs  before  the  process  of  softening  has  taken  place 
in  the  tubercular  deposit,  still  rarer  is  it  for  life  to  be  so  prolonged  as 
to  give  opportunity  for  the  occurrence  of  that  cretaceous  transformation 
by  which  the  disease  in  other  organs  is  sometimes  arrested.  MM.  Rilliet 
and  Barthez  have  observed  it  only  twice  out  of  87  cases  of  cerebral 


TUBERCLE   OF   THE   BRAIN — MORBID   APPEARANCES.  117 

tubercle ;  and  but  one  instance  of  it  has  come  under  my  notice,  in  a  boy 
&h  years  old,  in  whom  but  one  deposit  existed,  of  the  size  of  a  large  pea, 
situated  in  the  left  hemisphere  of  the  cerebellum.  The  change  was  in 
this  instance  incomplete,  when  death  took  place  from  acute  hydroce- 
phalus, succeeding  to  the  sudden  cessation  of  otorrhoea.  Had  the  child 
lived,  however,  it  is  probable  that  the  disease  would  have  been  altogether 
cured,  for  no  tubercles  were  present  in  any  other  organ  of  the  body, 
with  the  exception  of  the  bronchial  glands;  and  in  them  the  same 
curative  process  was  going  on. 

Cerebral  tubercle  does  not  invariably  affect  the  rounded  form,  but  it 
occasionally  extends  as  a  patch,  half  an  inch  or  more  in  length,  by  two 
or  three  lines  in  breadth,  immediately  beneath  the  pia  mater,  and  not 
reaching  above  one  or  two  lines  deep  into  the  cerebral  substance,  which 
is  usually  slightly  softened  beneath  it.  Now  and  then,  too,  the  deposit 
takes  place  not  in  distinct  and  isolated  masses,  but  in  the  form  of  infil- 
tration into  the  tissue  of  the  brain,  which,  in  this  situation,  is  of  a  rose- 
red  colour,  and  extremely  soft.  This  condition  has  come  twice  under 
my  notice,  and  was  associated  on  both  occasions  with  abundant  tuber- 
cular deposit  in  almost  all  the  viscera. 

These  tubercular  deposites  in  the  cerebral  substance  are  very  often, 
but  by  no  means  invariably,  associated  with  that  granular  state  of  the 
membranes  which  I  described  to  you  as  occurring  in  many  cases  of 
hydrocephalus.  Thickening  of  the  membranes,  and  effusion  of  hyaline 
matter  into  the  pia  mater  at  the  base  of  the  brain, — the  evidences,  in 
short,  of  meningitis, — are  often  present,  as  well  as  abundant  effusion  of 
fluid  into  the  ventricles,  and  softening  of  the  central  parts  of  the  brain. 
Sometimes,  however,  the  signs  of  inflammation  of  the  membranes  exist 
without  any  effusion  into  the  ventricles ;  and  in  a  few  instances  the 
ventricles  contain  an  abundance  of  fluid,  but  no  softening  of  the  central 
parts  of  the  brain  exists,  nor  any  sign  of  inflammation  of  the  membranes. 
I  know  of  no  instance  in  which  tubercle  was  limited  to  the  brain  in 
childhood ;  but  if  present  there,  it  always  exists  in  other  viscera,  and 
is  but  one  of  the  results  of  that  general  cachexia  which  may  shew  itself 
in  any  of  the  various  forms  of  scrofulous  or  phthisical  disease. 

I  am  unacquainted  with  any  special  cause  that  renders  the  brain 
more  liable  to  this  disease  in  childhood  than  in  adult  age,  or  even  in 
youth.  It  certainly  is  not  owing  simply  to  the  intensity  of  the  tuber- 
culous cachexia,  and  the  consequently  greater  abundance  of  the  morbid 
deposit,  for  I  have  met  with  many  instances  of  far  more  extensive 
tubercular  degeneration  than  existed  in  those  cases  where  the  brain  had 
Become  its  seat. 

Cases  are  not  yet  recorded  in  numbers  sufficient  for  us  to  determine 
accurately  the  time  of  the  greatest  liability  to  this  affection  :  Dr.  Green 
states  from  three  to  seven  years  of  age  to  be  the  period  of  its  greatest 
frequency ;  and  MM.  Rilliet  and  Barthez  likewise  consider  it  to  be  less 
usual  before  than  after  three  years  of  age.  Their  observations,  it 
should  be  remembered,  were  made  at  the  Hopital  des  Enfans  at  Paris, 
into  which  children  under  three  years  old  are  comparatively  seldom 
admitted.  It  seems  probable  that  their  estimate  of  the  age  at  which 
the  disease  most  commonly  occurs  is  somewhat  too  high,  for  17  out  of 


118  SYMPTOMS  OP  TUBERCLE  OP  THE  BRAIN. 

32  cases  recorded  by  Dr.  Mauthner  occurred  in  children  whose  age  did 
not  exceed  three  years ;  and  the  same  holds  good  with  reference  to  9 
out  of  14  fatal  cases  that  came  under  my  own  notice. 

We  come  now  to  the  examination  of  a  very  difficult  question — namely, 
that  of  the  symptoms  of  this  affection.  The  difficulty  arises  from  many 
sources ;  for  sometimes  the  disease  gives  rise  to  no  symptoms  at  all,  and 
its  existence  is  not  discovered  till  after  death  :  and  even  when  symptoms 
are  present,  neither  their  character  nor  their  intensity  bears  any  inva- 
riable relation  to  the  extent  of  the  local  mischief  or  its  seat ;  while, 
lastly,  the  symptoms  that  usually  betoken  tubercle  of  the  brain  some- 
times exist  where  no  such  morbid  growth  occupies  the  organ. 

Cases  in  which  no  symptom  whatever  marks  during  life  the  presence 
of  the  morbid  deposit  in  the  brain,  are  unusual.  Much  more  frequent 
are  those  in  which  the  sign3  of  cerebral  disturbance,  though  not  entirely 
absent,  are  too  vague  to  excite  much  attention,  and  too  slight  to  occa- 
sion much  suffering ;  so  that,  if  they  do  not  wholly  escape  notice,  they 
are  confounded  with  other  indications  of  ill  health  attendant  on  the 
general  tuberculization  with  which  this  disease  of  the  brain  is  frequently 
associated.  No  reason  can  be  assigned  for  this  latency  of  the  affection 
in  some  instances,  for  it  does  not  appear  to  depend  either  on  the  small 
size  of  the  tubercle  or  on  its  situation.  To  the  best  of  my  knowledge, 
however,  the  brain  in  the  immediate  neighbourhood  of  the  tubercular 
deposit  does  not  present  any  sign  of  softening  in  cases  which  have  been 
characterised  by  this  absence  of  the  signs  of  cerebral  disturbance.  It 
would  be  a  plausible  way  of  explaining  these  cases,  to  assume  that, 
when  symptoms  are  observed,  they  do  not  depend  simply  on  the  presence 
of  the  tubercle,  but  rather  on  the  changes  in  the  surrounding  brain.  This 
hypothesis,  however,  is  contradicted  by  the  fact  that  cerebral  symptoms 
sometimes  occur  in  cases  where  no  perceptible  disorganization  of  the 
brain  has  taken  place  either  around  the  tubercle  or  elsewhere. 

In  the  greater  number  of  instances,  the  absence  of  cerebral  symptoms 
lasts  only  to  within  a  short  time  of  the  patient's  death,  which  takes 
place  rather  suddenly  under  the  indications  of  most  serious  cerebral 
disease.  This  acute  stage  lasts  sometimes  for  a  few  hours  only,  and  a 
child  who  had  shown  no  sign  of  head  affection,  though  probably  the 
symptoms  of  phthisis  had  long  been  present,  suddenly  sinks  into  a  state 
of  stupor,  which  deepens  into  profound  and  fatal  coma.  In  other  cases 
a  fit  suddenly  takes  place,  followed  by  paralysis  of  one  limb,  or  of  the 
whole  of  one  side,  and  either  is  immediately  succeeded  by  coma,  or  the 
comatose  condition  comes  on  after  the  recurrence  once  or  oftener  of  the 
convulsions.  In  other  instances  the  fatal  event  is  preceded  by  t& 
symptoms  of  acute  hydrocephalus,  which  make  their  appearance  sud- 
denly, and  run  their  course  in  a  few  days ;  and  this  is,  perhaps,  the 
most  frequent  termination  of  the  disease.  This  sudden  outbreak  of 
symptoms  usually  takes  place  causelessly ;  but  I  have  seen  it  succeed 
to  a  blow  on  the  head,  even  though  not  severe,  or  follow  the  sudden  dry- 
ing-up  of  an  eruption  on  the  scalp,  or  the  sudden  suppression  of  a  dis- 
charge from  the  ear.  You  must  here  observe,  that,  though  I  have 
mentioned  various  ways  in  which  the  cerebral  disturbance  may  manifest 
itself,  yet  we  cannot  predicate,  from  differences  in  this  respect,  either 


SYMPTOMS   OP   TUBERCLE   OP  TIIE   BRAIN.  119 

the  seat  of  the  extent  or  the  deposite,  or  the  nature  of  the  mischief  that 
is  associated  with  it. 

Quite  as  variable,  and  equally  difficult  of  interpretation,  are  the 
symptoms  of  the  previous  stage,  in  which,  though  life  is  not.  in  imme- 
diate jeopardy,  yet  the  functions  of  the  brain  are  manifestly  disordered. 
Dr.  Hennis  Green,  in  his  valuable  paper  on  Tubercle  of  the  Brain  in 
Children,  published  in  Vol.  XXV.  of  the  Medico-Chirurgical  Transac- 
tions, mentions  pain  in  the  head  as  the  most  constant  symptom  of  this 
stage  of  the  affection,  he  having  met  with  it  as  a  prominent  feature  of 
the  disease  in  17  out  of  20  cases.  The  symptom  is  certainly  of  frequent 
occurrence,  but  it  attends  upon  so  many  other  affections,  that,  taken 
by  itself,  its  diagnostic  value  is  but  small. 

It  is  but  seldom  that  any  connection  can  be  traced  between  the  seat 
of  the  tubercle  and  the  situation  of  the  pain,  which  is,  for  the  most  part, 
referred  to  the  forehead.  It  is  often  very  severe,  so  that  during  its 
continuance  the  child  is  entirely  taken  up  with  its  suffering,  and  shrieks 
with  the  severity  of  the  pain ;  but  it  does  not  continue  with  this  inten- 
sity for  more  than  a  few  hours,  and  on  the  next  day  the  child  will  be 
found  to  be  no  worse  than  usual.  Vomiting  in  many  instances  attends 
these  exacerbations  of  pain ;  and,  when  this  is  the  case,  the  absence  of 
any  gastric  disorder  sufficient  to  account  for  it  will  lead  you  to  suspect 
the  presence  of  tubercle  in  the  brain.  In  some  cases,  however,  the 
headache,  though  severe,  does  not  present  this  remarkable  intensity, 
while  there  is  so  much  permanent  impairment  of  the  general  health, 
that  an  occasional  attack  of  sickness  does  not  surprise  you.  On  the 
other  hand,  you  will  meet  with  delicate  children  in  whom  attacks  of 
violent  headache,  sometimes  accompanied  by  vomiting,  will  come  on 
from  very  slight  causes,  or  apparently  without  any  cause  at  all,  and  will 
return  at  irregular  intervals  for  years  together,  till  they  gradually 
subside  as  the  health  becomes  more  robust,  and  cease  altogether  at  the 
period  of  puberty,  or  sooner.  In  infants,  and  in  children  under  two 
years  of  age,  we  of  course  lose  the  evidence  which  is  afforded  by  the 
patient's  complaints  of  headache,  and  can  only  infer  it  to  be  present 
from  the  occasional  loss  of  cheerfulness,  and  the  attacks  of  fretfulness  and 
crying.  Sometimes,  too,  the  suffering  of  the  brain  shows  itself  in  other 
ways  besides  headache.  The  temper  becomes  wayward  and  passionate, 
or  a  general  dulness  steals  over  all  the  faculties,  and  the  child  grows 
quite  indifferent  to  what  is  going  on  around  it.  One  little  boy,  aged 
two  years,  whom  I  watched  for  some  weeks  before  his  death,  never 
made  any  complaint  of  headache.  He  was  fretful,  and  cried  if  moved, 
but  was  perfectly  quiet  if  allowed  to  remain  in  his  chair,  where  he 
would  sit  half  dozing  for  hours  together. 

Affections  of  the  motor  system  are  often  among  the  early  indications 
of  this  disease,  but  neither  are  they  so  definite  as  to  present  anything 
pathognomonic  of  cerebral  tubercle.  A  boy  who  died  at  three  and  a 
half  years  old,  and  in  the  left  hemisphere  of  whose  cerebellum  there  was 
a  tubercle  as  large  as  a  pea,  had  been  subject  from  his  earliest  infancy 
to  an  almost  constant  and  involuntary  rotatory  movement  of  the  head 
when  in  the  recumbent  posture.  And  in  another  boy,  who  was  two 
years  old  at  death,  the  head  had  hung  for  four  months  towards  the  left 


120  SYMPTOMS   OP   TUBERCLE   OF   THE   BRAIN. 

shoulder  before  any  other  symptom  of  mischief  in  the  brain  appeared : 
convulsions  then  suddenly  came  on,  and  the  child  died  in  72  hours. 
Sometimes  paralysis  of  a  limb  comes  on  gradually  ;  or,  though  actual 
paralysis  does  not  exist,  yet  the  power  over  one  side  becomes  greatly 
weakened,  and  the  child  drags  one  leg,  or  is  observed  invariably  to  use 
one  arm  in  preference  to  the  other.  Convulsive  movements,  however, 
are  the  most  frequent  of  the  affections  of  the  motor  system ;  and  para- 
lysis of  a  limb,  or  impaired  power  over  it,  usually  succeeds  to  their 
occurrence,  and  but  seldom  takes  place  independently  of  them.  Some- 
times we  observe  nothing  more  than  occasional  attacks  of  convulsive 
twitching  of  one  limb  (oftener  of  the  arm  than  of  the  leg),  unattended 
by  any  loss  of  consciousness  or  impairment  of  intellect ;  but  the  seizure 
is  more  frequently  attended  by  insensibility,  though  the  convulsive 
movement  may  be  limited  to  one  side,  or  even  to  one  limb.  Convulsions 
affecting  one  side  only  are  sometimes  seen,  although  tubercle  is  present 
in  both  hemispheres  ;  or  in  other  instances  both  sides  are  affected  by 
the  convulsions,  and  yet  the  deposite  is  found  only  in  one  hemisphere 
of  the  brain.  When  convulsions,  whether  general  or  partial,  have  once 
occurred,  they  are  seldom  absent  for  many  days  together,  though  to 
this  there  are  occasional  exceptions,  in  which  a  pause  of  many  months 
ensues  after  the  first  convulsive  seizure  ;  the  general  health,  indeed, 
being  impaired,  but  no  sign  indicating  the  special  mischief  that  exists 
in  the  brain. 

The  transition  from  the  premonitory  to  the  acute  stage  sometimes 
takes  place  gradually,  the  convulsions  becoming  more  and  more  fre- 
quent, and  the  other  cerebral  symptoms  more  serious,  and  the  intervals 
of  freedom  from  suffering  shorter ;  or  the  change  takes  place  suddenly, 
and  without  such  previous  increase  in  the  severity  of  the  child's 
sufferings  as  to  make  you  anticipate  its  approaching  death  ;  and  yet 
we  cannot  always  discover  such  differences  between  the  morbid  appear- 
ances in  the  two  cases  as  suffice  to  explain  the  dissimilar  course  of  the 
disease. 

Wide  as  the  differences  are  between  the  effects  mentioned  as  produced 
by  cerebral  tubercle  in  one  case,  from  those  which  are  observed  in 
another,  they  are  not,  perhaps,  so  altogether  inexplicable  as  at  first 
sight  they  may  appear.  The  size  or  position  of  the  deposit,  or  the 
rapidity  of  its  growth,  may  in  one  case  produce  pressure  on  the  brain, 
occasion  the  effusion  of  fluid,  and  thus  cause  the  patient's  death  ;  or  the 
accidental  congestion  of  the  brain  following  the  arrest  of  some  dis- 
charge, or  the  healing  of  some  eruption,  or  attending  on  some  inter- 
current febrile  disorder,  may  render  it  sensible  of  the  presence  of  the 
morbid  deposite  which  it  had  endured  quietly  for  weeks  or  months,  and 
all  the  indications  of  serious  cerebral  irritation  may  at  once  become 
apparent.  In  another  case  softening  may  take  place  in  the  tubercular 
mass,  and  extending  to  the  adjacent  tissue,  inflammation  of  the  brain 
may  be  lighted  up;  or  the  deposite  not  being  limited  to  the  brain  itself, 
but  affecting  its  envelopes  also,  tubercular  meningitis  may  supervene,  as 
it  often  does,  and  destroy  the  patient. 

These  considerations  may  serve  to  explain  cases  where  the  tubercular 
deposit  has  been  found  external  to  the  substance  of  the  brain,  merely 


SYMPTOMS   OP   TUBERCLE   OP   THE   BRAIN.  121 

pressing  on  it,  but  in  no  way  altering  its  tissue.  Such  a  case  I  once 
saw  in  the  person  of  a  little  girl,  10  years  old,  who  for  five  months  had 
suffered  from  strumous  disease  of  the  knee-joint,  but  had  never  mani- 
fested any  head  symptom  during  her  six  weeks'  stay  in  the  Middlesex 
Hospital.  She  was  taken  home  at  the  end  of  this  time,  but  had  not 
left  the  hospital  many  hours  when  convulsions  of  the  right  side  came 
on,  which  were  succeeded  by  coma  ;  and  this  deepened,  till  in  the  course 
of  forty-eight  hours  it  became  absolute.  Convulsions  occasionally 
returned,  always  affecting  the  right  side,  which  from  the  first  con- 
tinued paralysed  in  the  intervals  between  their  occurrence.  She  lay 
thus  for  eight  days  without  any  sign  of  amendment,  and  then  died. 
There  was  a  large  quantity  of  clear  serum  in  the  lateral  ventricles,  and 
much  escaped  from  the  spinal  canal.  There  was  no  disease  of  the  brain, 
nor  any  important  morbid  appearance  in  the  spinal  cord  ;  but  there  was 
disease  about  the  odontoid  process  and  its  articulation  with  the  atlas, 
with  a  collection  of  tubercular  matter  around  it,  forming  a  tumor  which, 
situated  in  the  mesial  line,  encroached  somewhat  on  the  occipital  fora- 
men, though  pressing  but  very  slightly  on  the  cord.  In  the  quiet  of 
the  hospital  this  disease  had  produced  no  symptom  ;  the  excitement  of 
her  return  home  kindled  the  spark,  and  destroyed  the  patient. 

Bearing  these  things  in  mind,  too,  we  can  account  for  the  sudden 
death  of  a  child,  in  whom  a  solitary  tubercle  in  the  brain  had  already 
passed  into  the  cretaceous  state,  but  where  habitual  otorrhoea  had  ceased 
suddenly  ;  and  we  can  understand  the  reason  for  the  intermittent  cha- 
racter which  the  symptoms  of  cerebral  tubercle  so  frequently  assume.1 

I  do  not  wish  for  one  moment  to  exaggerate  the  difficulties  that  attend 
the  diagnosis  of  this  affection ;  but  at  the  same  time,  if  we  assume  that 
we  have  to  do  with  an  incurable  disease,  we  are  less  likely  to  use  effi- 
cient means  of  treatment  than  if  we  felt  that  there  is  still  some  room 
for  hope.  While,  therefore,  I  would  have  you  bear  in  mind  that  the 
symptoms  which  we  have  been  passing  in  review,  especially  if  associated 
with  indications  of  tubercle  in  other  organs,  render  the  presence  of 
tubercle  in  the  brain  in  the  highest  degree  probable,  they  yet  do  not 
afford  absolutely  certain  evidence  of  it.  Headache,  aggravated  at 
intervals,  and  associated  with  occasional  convulsive  movements  of  one 
limb,  and  even  with  attacks  of  an  epileptic  character,  may  occur  in 
children  who  yet  after  a  time  recover,  and  shew,  by  the  robust  health 
they  subsequently  attain  to,  that  some  cause  of  a  less  abiding  nature 
than  tubercular  deposit  must  have  given  rise  to  the  disturbance  of  the 
brain ;  or,  on  the  other  hand,  though  serious  cerebral  disease  may  exist, 
and  such  as  gives  rise  at  length  to  a  fatal  result,  yet  it  may  appear 
after  death  that  it  was  such  as  would  have  been  mitigated,  if  not  cured, 
by  appropriate  treatment. 

You  must  not,  then,  be  merely  passive  spectators  of  these  symptoms ; 
and,  if  you  watch  cases  of  this  kind  with  attention,  you  will  generally 
find  that  they  afford  you  some  clue  to  the  treatment  that  you  should 
follow.     Either  there  is  manifest  gastric  and  intestinal  disorder,  or 

1  See,  with  reference  to  the  various  effects  of  cerebral  tubercle,  and  the  different 
■ways  in  which  it  may  prove  fatal,  the  excellent  chapter  on  tubercle  of  the  brain  in 
Dietl's  work,  already  referred  to,  p.  346 — 35b*. 


122  DIAGNOSIS   AND   TREATMENT   OE  TUBERCLE   OP   THE   BRAIN. 

there  are  indications  of  a  state  of  general  debility,  or  there  are  signs  of 
inflammatory  disease  in  the  brain.  In  the  first  case,  the  regulation  of 
the  bowels,  and  the  careful  management  of  the  diet,  are  obviously  indi- 
cated; in  the  second,  iron  may  be  given  with  advantage,  and  the 
shower-bath  may  be  cautiously  tried,  and,  if  it  do  not  alarm  the  child, 
it  may  often  be  continued  with  much  benefit.  In  those  cases  where 
there  seems  to  be  some  slow  mischief  in  the  brain,  I  have  once  or  twice 
seen  recovery  take  place,  contrary  to  all  my  anticipations,  from  the 
employment  of  small  doses  of  mercury  night  and  morning,  persevered 
with  for  many  weeks.  In  such  cases,  too,  counter-irritation  by  means 
of  the  tartar-emetic  ointment  rubbed  into  the  back  of  the  neck  is  often 
followed  by  the  happiest  effects.  A  little  girl,  14  months  old,  was 
some  time  since  under  my  care  for  the  frequent  recurrence  of  convul- 
sive attacks  of  a  very  anomalous  character.  So  long  as  a  discharge  was 
kept  up  from  her  neck  by  the  tartar-emetic  ointment,  the  fits  did  not 
occur ;  but  if  the  discharge  ceased  for  two  or  three  days,  they  were 
sure  to  return. 

These  are  the  principles  by  which  your  conduct  must  be  governed  ; 
but  you  will  find  that  each  case  will  present  some  special  peculiarity, 
and  will  need  to  be  studied  and  treated  for  itself. 

Tumors  of  other  kinds  may  exist  in  the  brain  in  childhood,  though 
they  appear  to  be  more  frequent  in  the  middle-aged  or  the  old.  I  once 
saw  a  case  in  which  hydatids  had  formed  in  the  substance  of  the  brain 
in  a  girl  of  seven  years  old ;  and  once  also  I  saw  cancer  affecting  the 
brain  and  its  membranes  in  a  boy  two  and  a  half  years  old.  But, 
though  such  occurrences  are  interesting  from  their  rarity,  I  do  not 
know  any  circumstance,  except  the  absence  of  the  signs  of  tubercular 
disease  in  the  patient,  by  which  you  could  determine  during  life  that 
certain  cerebral  symptoms  arise  from  hydatids  or  cancer  of  the  brain, 
and  not  from  tubercle  in  that  organ. 


LECTUEE    XI. 

Diseases  of  the  Spinal  Cord — their  study  rendered  more  difficult  by  the  tender  age 
of  children. 

Irritation  and  Congestion  of  the  Cord. 

Inflammation  of  the  Membranes  of  the  Cord — sometimes  epidemic — not  common  as  a 
sporadic  affection.  Illustrative  cases. — Inflammation  of  the  Substance  of  the 
Cord— extremely  rare  in  its  acute  form — in  its  chronic  form  gives  rise  to  symptoms 
similar  to  those  which  occur  when  bones  of  the  spine  are  diseased.     Cases. 

Trismus — extremely  rare  in  this  country — symptoms — post-mortem  appearances — 
uncertainty  as  to  natural  vascularity  of  the  cord  in  early  infancy.  Causes  of  the 
disease — influence  of  vitiated  air — treatment  almost  hopeless. 

At  the  commencement  of  these  lectures  I  called  your  attention  to 
the  predominance  of  the  spinal  over  the  cerebral  part  of  the  nervous 
system,  as  constituting  one  of  the  grand  characteristics  of  early  life. 
Since  then,  our  daily  course  of  inquiry  has  brought  before  us  numerous 
confirmations  of  this  truth,  and  has  shown  us  how  slight  a  disturbance 


IRRITATION   AND   CONGESTION   OF   THE   SPINAL   CORD.  123 

of  the  functions  of  the  brain  may  suffice  to  destroy  the  harmony  of  those 
which  belong  to  the  spinal  cord. 

This  morning  we  pass  from  the  consideration  of  those  cases  in  which 
the  brain  is  the  original  seat  of  disorder,  and  in  which  the  spinal  cord 
suffers  only  secondarily,  to  the  study  of  others,  in  which  that  organ  is 
itself  primarily  affected.  I  need  not  remind  you  how  much  obscurity 
hangs  over  the  ailments  of  the  spinal  cord  at  all  periods  of  life  ;  but  in 
the  young  subject  this  is  not  a  little  increased  by  the  difficulty  that 
attends  the  observation  of  some  of  those  symptoms  which  would  be 
obvious  enough  in  the  adult.  Thus,  for  instance,  while  impairment  or 
loss  of  the  locomotive  power  in  the  grown  person  could  hardly  escape 
our  notice  for  a  moment,  it  might  fail  to  attract  much  attention  in  a 
young  child,  who  often  totters  in  his  gait,  or  even  becomes  unable  to 
walk,  if  from  any  cause  his  health  should  fail.  Or,  again,  the  impaired 
sensation,  or  the  vague  pains  in  the  limbs,  which  the  adult  would  be 
sure  to  tell  us  of,  would  be  but  ill  described  by  a  child,  even  though  it 
had  long  been  able  to  talk,  while  terror  might  cause  it  to  cry  if  any 
attempt  were  made  to  examine  its  back,  and  might  thus  prevent  our 
ascertaining  the  presence  or  absence  of  tenderness  of  the  spine.  These 
are  difficulties,  however,  which  patience  and  tact  will  overcome  ;  for  not 
only  the  diseases  of  the  spinal  cord,  but  the  symptoms  by  which  they 
manifest  themselves,  are  much  the  same  at  all  ages,  the  chief  difference 
being  that  in  the  one  case  they  strike  the  eye  even  of  the  careless, 
while  in  the  other,  careful  observation  is  necessary  for  their  detection. 

Irritation  of  the  cord,  however  produced,  gives  rise  in  the  child,  as 
well  as  in  the  adult,  to  impairment  of  the  motor  power.  A  little  boy, 
between  two  and  three  years  old,  remarkably  strong  and  healthy,  was 
observed,  without  any  obvious  cause,  to  fail  in  his  general  health,  and 
at  the  same  time  to  totter  in  his  gait,  to  become  indisposed  to  move, 
and,  at  last,  almost  entirely  to  cease  walking ;  and  this  impairment  of 
his  power  of  walking  was  quite  out  of  all  proportion  to  the  signs  of  ill 
health  by  which  it  was  attended.  After  watching  him  for  a  time,  it 
was  discovered  that  the  child  had  become  addicted  to  the  practice  of 
masturbation.  This  was  put  a  stop  to,  and  he  soon  regained  his  health, 
and  with  it  his  power  of  walking. 

The  mischief  to  the  cord  may  be  more  serious,  and  the  symptoms 
will  then  present  a  corresponding  increase  of  severity. 

In  May,  1845,  a  little  girl,  four  years  old,  was  brought  to  me  by  her 
mother,  who  said  that  ten  days  before,  the  child  had  had  a  fall  on  her 
back,  while  left  in  tn*e  charge  of  a  servant,  and  that  on  the  following 
morning  she  was  unable  to  stand  or  move,  unless  supported;  and  that 
she  had  ever  since  continued  in  the  same  condition.  Her  appearance 
was  rather  anxious  ;  her  face  slightly  flushed ;  skin  warm  and  dry  ; 
tongue  slightly  furred ;  pulse  frequent,  and  with  power.  If  placed  on 
her  feet  she  clung  hold  of  her  mother,  sank  down  into  a  stooping,  half- 
squatting  posture,  and  immediately  began  to  cry.  She  could  walk  if 
firmly  supported,  but  hurriedly  and  unsteadily,  stepping  on  her  toes, 
her  legs  moving  in  a  semi-circle  with  her  toes  turned  inwards,  and  one 
foot  being  put  down  just  in  front  of  the  other.  On  examining  the 
spine,  the  integuments  from  the  tenth  to  the  twelfth  dorsal  vertebra 


124  MENINGITIS   OF   THE   SPINAL   CORD. 

presented  a  little  puffiness,  and  there  was  very  great  tenderness  of  the 
spine  in  that  situation  ;  and  even  when  not  touched,  the  child  com- 
plained of  pain  in  her  hack.  There  was  no  appetite,  hut  great  thirst ; 
the  bowels  were  constipated  ;  the  appearance  of  the  urine  was  natural, 
and  neither  feces  nor  urine  were  voided  unconsciously. 

She  was  cupped  on  the  loins  to  Sit.,  and  on  the  following  day  w'as 
much  relieved,  moving  her  legs  more  readily,  and  suffering  much  less 
from  pain  in  the  back.  On  the  17th  she  was  able  to  stand,  and  could 
walk  a  little  without  suffering.  Attention  was  paid  to  keep  the  bowels 
open,  and  in  a  few  days  she  wa3  quite  well. 

It  is  probable  that  in  this  case  nothing  more  serious  was  the  matter 
than  some  degree  of  congestion  of  the  spinal  cord  or  its  membranes ; 
but  we  likewise  meet  occasionally  with  instances  of  inflammation  of 
these  parts. 

Inflammation  of  the  membranes  of  the  spinal  cord  prevailed  epidemi- 
cally in  many  parts  of  France  from  1842  to  1844.  The  victims  of  the 
disease,  which  proved  very  fatal,  were  almost  entirely  youths  a  little 
past  the  period  of  puberty.  An  epidemic  of  a  similar  kind  was  lately 
prevalent  in  many  of  the  hospitals  and  workhouses  of  Ireland ;  but  in 
that  country  boys  under  twelve  years  of  age  were  almost  the  only  per- 
sons who  suffered  from  it.  The  arachnoid  of  the  spinal  cord  was  found 
in  every  instance  to  be  the  part  chiefly  affected,  though  in  most  cases 
the  membranes  of  the  brain  seem  to  have  been  slightly  involved  in  the 
disease.  Notwithstanding  the  great  extent  of  the  inflammation  of  the 
membranes  of  the  cord,  and  the  effusion  of  lymph  beneath  them,  the 
nervous  substance  appears  to  have  been  comparatively  seldom  attacked 
by  it,  and  never  with  much  severity.  The  disease  generally  came  on 
very  suddenly,  and  its  course  was  often  extremely  rapid,  some  patients 
dying  in  twenty-four  hours,  while  few  survived  the  fourth  day.  Severe 
pain  in  the  abdomen,  attended  with  vomiting  and  purging,  and  a  con- 
dition of  general  collapse,  marked  the  outset  of  the  affection.  A  state 
of  reaction  soon  succeeded,  the  surface  in  the  course  of  a  few  hours 
becoming  hot,  the  pulse  full,  and  its  frequency  varying  from  120  to 
140,  while  the  face  assumed  a  tetanic  expression,  and  the  head  was 
retracted  and  firmly  fixed.  General  convulsions,  or  coma,  succeeded 
to  this  condition,  and  the  failure  of  deglutition,  with  a  slow  and  laboured 
pulse,  followed  as  the  immediate  precursors  of  death. 

I  must  refer  you  to  Dr.  Mayne's  account  of  this  epidemic,  which  is 
contained  in  the  Dublin  Quarterly  Journal  for  August,  1846,  for  I  have 
not  seen  the  disease  in  any  other  than  a  sporadic  form,  and  even  then 
but  seldom.  Perhaps,  therefore,  I  shall  convey  to  you  a  more  truthful 
impression  of  the  general  characters  of  inflammatory  affections  of  the 
spinal  cord  and  its  membranes,  by  relating  to  you  a  few  of  those 
instances  that  have  come  under  my  own  notice,  rather  than  by 
attempting  to  draw  a  general  portraiture  of  them  from  too  small  a 
number  of  examples. 

A  boy,  aged  11  years,  of  phthisical  family,  who  seven  months  pre- 
viously had  had  severe  and  long-continued  attacks  of  headache,  was 
greatly  distressed  by  hearing  of  the  sudden  death  of  a  relation.  On  the 
following  day  he  had  slight  nausea,  with  pain  in  the  head  ;  but  in  a  day 


MENINGITIS  OF  THE  SPINAL   CORD.  125 

or  two  lie  suffered  more  from  pain  in  his  limbs,  especially  in  the  calves 
of  the  legs,  and  also  shooting  from  the  situation  of  the  coccyx  to  the 
middle  of  the  back.  He  complained,  moreover,  of  a  constant  pain  at 
the  epigastrium,  which,  as  well  as  that  about  the  lower  part  of  the  back, 
was  always  much  aggravated  when  the  bowels  acted ;  they  being,  how- 
ever, usually  constipated.  These  symptoms  were  associated  with  great 
weakness  of  the  legs,  which  he  dragged  when  walking,  and  reached  the 
Children's  Infirmary,  from  which  his  home  was  about  a  mile  distant, 
with  much  difficulty.  On  the  following  day  I  visited  him,  and  ascer- 
tained; on  examining  the  spine,  that  there  was  considerable  tenderness 
on  pressure  from  about  the  middle  of  the  dorsal  vertebrae  to  the  apex 
of  the  sacrum,  but  greatest  about  the  lumbar  region.  There  was  no 
intolerance  of  light,  but  very  distressing  sense  of  giddiness,  complete 
loss  of  appetite,  constant  sensation  of  sickness,  and  a  nasty  taste  in  the 
mouth.  The  intellect  during  the  whole  illness  was  only  once  affected, 
and  then  but  for  a  few  hours  ;  and  the  child  was  remarkably  acute, 
and  described  his  different  sensations  with  great  exactness. 

The  pain  in  the  loins  was  relieved  by  cupping ;  but  on  the  next  day 
the  headache  was  increased  in  severity,  and  there  was  some  subsultus 
of  the  tendons  of  the  forearms,  and  a  good  deal  of  twitching  of  the 
hands.  This  symptom  disappeared  after  the  boy  had  been  depleted 
copiously  by  leeches  to  the  head,  and  after  his  gums  had  begun  to  be 
affected  by  mercury,  which  was  freely  administered  to  him  ;  but  his 
pulse,  which  during  the  whole  of  his  illness  never  exceeded  75,  sank  to 
60  in  the  minute,  and  its  beat  became  irregular.  As  the  mouth  became 
decidedly  sore,  first  the  shooting  pains  in  the  back  and  limbs  ceased ; 
then  the  pulse  became  regular,  and  rose  in  frequency ;  then  the  epi- 
gastric pain  disappeared,  and  was  succeeded  for  a  time  by  a  sense  of 
weight  there.  By  degrees  the  tenderness  of  the  spine  diminished,  and 
finally  ceased,  and  the  headache  grew  less  ;  but  his  legs  long  continued 
weak,  so  that  he  could  not  tread  firmly,  and  the  slightest  noise,  or  any 
kind  of  over-exertion,  brought  on  an  immediate  increase  of  his  sufferings. 
A  seton  was  put  in  the  back  of  his  neck,  and  the  influence  of  mercury 
on  the  system  was  cautiously  maintained  for  four  months  before  the 
boy  appeared  sufficiently  well  to  justify  the  discontinuance  of  remedies. 

But  the  disease  may  run  a  more  acute  course,  and  to  a  less  favourable 
termination. 

A  little  boy,  one  year  old,  who  had  cut  four  incisor  teeth,  and  whose 
health  had  been  habitually  good,  was  brought  to  me  by  his  mother  after 
three  weeks'  illness.  She  told  me  that  he  had  been  suddenly  seized  with 
great  fever  and  heat  of  skin,  accompanied,  after  the  lapse  of  four  days, 
by  violent  screams.  At  the  outset  of  his  illness  he  had  been  cupped  at 
the  back  of  his  neck,  and  leeches  had  been  applied  to  the  head,  without 
amendment,  and  for  a  week  before  I  saw  him  all  treatment  had  been 
discontinued.  The  child  then  lay  in  his  mother's  lap,  frequently  crying 
with  a  low  distressed  whimper ;  his  face  was  usually  pale,  but  occasion- 
ally flushed ;  his  head  was  thrown  back,  so  that  the  occiput  and  back  of 
the  neck  were  nearly  in  contact  with  each  other.  The  sterno-mastoid 
muscles  were  rather  rigid,  though  there  was  no  trismus.  The  hands  were 
clenched,  the  thumbs  drawn  into  the  palm,  and  occasional  attacks  came 


126  MENINGITIS   OF   THE   SPINAL   CORD. 

on,  in  which  he  uttered  a  scream,  and  then  bent  his  body  back  into  an 
arch.  The  child  sucked  eagerly,  but  frequently  dropped  the  nipple  as  if 
in  pain ;  the  pupils  acted  naturally ;  the  pulse  was  frequent,  small,  and 
hard.  In  the  course  of  the  succeeding  day  frequent  convulsive  twitch- 
ings  and  startings  of  the  limbs  took  place,  affecting  the  left  arm  more 
than  any  other  part.  His  face  grew  habitually  pale  and  more  sunken, 
and  the  spine  became  habitually,  though  slightly,  curved  forwards,  not- 
withstanding which,  occasional  attacks  of  opisthotonos  still  occurred. 
The  pupils  still  acted  well,  but  a  new  symptom  appeared,  in  the  laboured 
breathing,  which  sometimes  became  so  difficult  that  the  child  seemed 
almost  choking,  while  phlegm  collected  in  his  throat,  which  he  appeared 
unable  to  get  rid  of.  This  dyspnoea  would  almost  imply  that  the  inflam- 
mation had  been  gradually  travelling  upwards  till  it  began  to  involve  the 
origins  of  the  cerebral  nerves — a  supposition  still  further  confirmed  by 
finding  two  days  afterwards  that  the  eyeballs  were  in  a  state  of  constant 
convulsive  rotation.  After  this,  which  was  the  fifth  day  from  that  on 
which  I  first  saw  the  child,  he  was  not  again  brought  to  me ;  but,  though 
this  case  is  incomplete,  it  yet  helps  to  fill  up  the  portraiture  of  the 
disease.  To  complete  it,  however,  I  must  relate  one  instance  more,  in 
which  the  results  of  examination  after  death  confirmed  the  diagnosis. 

Some  years  ago,  I  saw  a  little  boy,  five  months  old,  of  whom  his 
mother  gave  me  the  following  history  : — A  month  before  he  had  been 
attacked  with  shivering  (an  unusual  occurrence  in  a  young  child),  and, 
in  the  night  following  this  seizure,  had  many  fits,  during  which  he 
screamed  much  and  became  very  stiff.  After  they  had  continued  for 
three  days,  returning  at  intervals  of  an  hour  or  half  an  hour,  a  little 
diminution  in  their  severity  followed  the  use  of  some  medicine  pre- 
scribed for  him  by  a  surgeon  ;  but,  even  when  I  saw  him,  ten  or  twelve 
often  occurred  in  the  twenty-four  hours,  though  a  day  would  now  and 
then  pass  without  any.  The  fits  were  described  as  presenting  the 
characters  of  opisthotonos,  though  in  a  less  marked  degree  than  when 
they  first  came  on.  The  retraction  of  the  head  with  which  they  were 
attended  at  first,  subsided  after  their  cessation ;  but  in  the  course  of 
two  or  three  days  a  tendency  to  keep  the  head  constantly  thrown  back 
became  evident,  and  for  a  fortnight  the  head  had  never  been  brought 
out  of  that  position.  The  mother  thought,  too,  that  the  child  had  been 
blind  for  that  period. 

The  child  appeared  well  grown  and  well  nourished,  and  the  face  was 
not  expressive  of  particular  suffering,  but  the  head  was  drawn  back  so 
that  the  occiput  rested  between  the  shoulders,  while  the  back  was  bent 
forwards  in  a  state  of  perfect  emprosthotonos :  the  legs  were  drawn  up 
towards  the  abdomen,  the  palms  of  the  hands  turned  backwards  and 
outwards,  the  fingers  clenched,  and  the  thumbs  drawn  into  the  palm. 
On  turning  the  child  round  on  its  face,  its  body  formed  a  complete  arch 
resting  on  the  chin  and  knees.  The  whole  spine  was  very  tender,  and 
this  tenderness  was  greatest  about  its  upper  part.  The  pupils  were 
dilated  and  immoveable  ;  suction  was  difficultly  performed,  though  there 
was  no  trismus,  but  the  child  vomited  everything  it  took  almost  imme- 
diately. The  pulse  was  at  this  time  too  rapid  and  too  feeble  to  be 
counted,  and  the  child  died  in  a  fit  of  convulsions  twenty-four  hours 
afterwards. 


ACUTE   INFLAMMATION   OF   THE   SUBSTANCE  OF   THE   CORD.  127 

On  examining  the  body,  blood  was  found  effused,  though  not  in  any 
considerable  quantity,  within  the  spinal  canal,  but  external  to  the  dura 
mater,  from  the  third  cervical  to  the  third  dorsal  vertebra.  A  thick 
layer  of  white  lymph  was  present  both  under  the  arachnoid  and  in  its 
cavity  along  the  whole  posterior  surface  of  the  lumbar  and  dorsal  por- 
tions of  the  cord,  and  likewise  existed  in  the  cervical  portion,  though 
in  a  less  degree.  Anteriorly,  blood  and  lymph  occupied  the  whole  cer- 
vical portion  of  the  sac  of  the  arachnoid,  and  were  effused  beneath  the 
membrane ;  but  in  the  remainder  of  the  front  of  the  cord  there  were 
merely  patches  of  lymph  beneath  the  arachnoid.  The  substance  of  the 
cord  was  apparently  healthy.  On  lifting  up  the  cerebellum,  a  con- 
siderable quantity  of  serum,  with  flakes  of  lymph,  escaped  from  the 
base  of  the  skull,  and  the  whole  under  surface  of  the  cerebellum  had  a 
uniform  coating  of  white  lymph  at  least  a  line  and  a  half  in  thickness, 
which  extended  over  the  medulla  oblongata,  and  was  continuous  with 
the  deposit  of  lymph  along  the  spinal  cord.  The  lateral  ventricles  of 
the  brain  were  much  distended  with  fluid,  in  which  large  irregular 
masses  of  yellow  lymph  were  floating.  The  corpora  striata  and  the 
fornix  were  much  softened,  but  the  rest  of  the  brain  and  the  membranes 
at  its  convexity  were  quite  healthy. 

It  can  scarcely  be  necessary  that  I  should  comment  on  these  cases, 
either  to  point  out  to  you  the  many  respects  in  which  inflammation  of 
the  spinal  cord  differs  from  that  of  the  brain,  or  to  insist  on  the  absolute 
necessity  of  active  antiphlogistic  treatment  being  adopted  at  the  very 
outset  of  the  disease. 

I  apprehend  that  in  the  case  that  recovered,  as  well  as  in  the  other 
two  which  terminated  fatally,  the  membranes  were  chiefly,  if  not  exclu- 
sively, affected.  I  have  not  met  with  any  instance  of  acute  inflamma- 
tion and  consequent  softening  of  the  substance  of  the  spinal  cord, 
although  there  are  many  such  on  record.  It  has  been  supposed  that 
paralytic  symptoms  usually  attend  this  affection,  while  stiffness  and 
spasms  of  the  muscles  characterise  spinal  meningitis  ;  but  though  this 
is  probably  true  in  many  instances,  yet  it  does  not  by  any  means  hold 
good  in  all.  Three  cases  are  related  by  MM.  Rilliet  and  Barthez,  in 
which  the  disease  ran  its  course  with  symptoms  of  tetanus  and  trismus, 
which  continued  up  to  the  time  of  the  patient's  death.  In  one  of  these 
cases  the  child  died  in  36  hours ;  in  the  second,  in  96  hours  ;  but  in  the 
third,  a  temporary  remission  having  occurred,  the  patient  survived  for 
thirteen  days. 

I  select  from  Dr.  Mauthner's  valuable  treatise  on  the  Diseases  of  the 
Brain  and  Spinal  Cord  in  Children,  a  very  characteristic  case  of  acute 
inflammatory  softening  of  the  spinal  marrow.1 

A  girl  aged  11  years,  whose  occupation  as  a  sempstress  compelled 
her  to  remain  for  many  hours  daily  in  a  sitting  posture,  with  her  head 
bent  forwards,  while  she  was  at  the  same  time  much  exposed  to  currents 
of  cold  air,  was  seized,  after  she  had  followed  this  employment  for  three 
weeks,  with  dragging  and  tearing  pains  in  the  back  of  her  neck.  As 
these  pains  increased,  voluntary  power  over  the  arms  became  impaired, 

1  Lib.  cit.  p.  421,  case  117. 


128      ACUTE  INFLAMMATION  OP  THE  SUBSTANCE  OP  THE  CORD. 

and,  the  paralysis  increasing  rapidly  in  spite  of  the  application  of 
leeches  to  the  back  of  the  neck,  she  was  admitted  into  the  Hospital  for 
Children  at  Vienna,  under  Dr.  Mauthner's  care,  on  Dec.  26th.  «Both 
arms  were  at  that  time  completely  palsied,  flaccid,  cool,  and  almost 
insensible ;  the  lower  extremities  still  obeyed  the  will,  but  the  girl  was 
unable  to  stand  firmly.  The  mind  was  perfectly  clear,  the  appetite 
good,  deglutition  easy,  and  pulse  natural ;  and  in  these  respects  her 
condition  continued  unchanged  to  the  very  last,  except  that  the  pulse 
became  very  frequent  on  the  day  of  the  child's  death.  On  the  28th, 
tlie  legs  were  palsied,  and  the  urine  was  passed  involuntarily.  On  the 
29th,  voluntary  power  over  the  hands  and  feet  was  likewise  completely 
lost,  and  sensation  in  them  was  very  imperfect.  On  the  30th,  sensa- 
tion was  perfectly  lost  in  all  the  extremities.  The  child  had  desire  to 
pass  feces,  the  bowels  not  having  acted  for  three  days,  but  she  had  not 
power  to  do  so.  On  the  31st,  the  sphincter  ani  was  likewise  paralysed, 
and  opened  to  the  size  of  a  shilling.  On  January  4th  the  hardened 
faeces  began  to  fall  out  of  the  gaping  anus ;  the  respiration  was  feeble, 
articulation  difficult.  On  the  6th  the  child  was  in  much  distress,  and 
for  many  days  had  scarcely  slept  at  all ;  the  whole  left  side  of  the  body 
was  completely  paralysed,  and  only  the  right  side  of  the  chest  moved 
in  respiration.  Her  exhaustion  was  so  extreme  that  her  voice  was 
scarcely  audible,  but  the  muscles  of  the  face  still  retained  the  power  of 
motion  and  sensation  perfectly,  and  the  intellect  was  quite  clear,  though 
the  child  died  the  same  night. 

The  spinal  cord  presented  the  only  morbid  appearance,  the  mem- 
branes being  perfectly  healthy.  The  medulla  oblongata  was  as  soft  as 
butter,  of  a  yellow  colour,  not  presenting  a  trace  of  its  natural  organi- 
sation ;  and  the  same  condition  was  presented  by  the  whole  of  the 
spinal  cord  as  low  as  the  cauda  equina,  where  it  once  more  resumed  its 
natural  appearance  and  characters. 

The  chroicn  form  of  inflammation  of  the  cord  will  much  oftener 
come  under  your  notice  as  one  of  the  consequences  of  caries  of  the  ver- 
tebrae. You  will  remember,  too,  that  this  serious  result,  and  the  para- 
lysis to  which  it  gives  rise,  are  not  produced  simply  by  the  distortion 
of  the  spine  and  the  mechanical  compression  of  the  cord,  but  rather  by 
extension  to  it  of  the  inflammatory  action.  You  have,  then,  in  these 
cases  a  double  danger  to  combat ;  both  that  which  arises  from  the  dis- 
ease in  the  spinal  column  itself,  and  that  which  depends  on  the  probable 
extension  to  the  cord  of  the  disease  which  began  in  the  bones.  The 
symptoms  of  the  two  affections  present  likewise  so  many  points  of 
resemblance  in  their  early  stages  that  you  can  never  feel  sure  that  the 
cord  is  uninvolved.  Of  this  we  have  ample  proof  in  those  rare  cases  in 
which  chronic  softening  of  the  cord  occurs  independent  of  any  affection 
of  the  bones  of  the  spine.  You  will  find  a  case  that  illustrates  this  fact 
very  well  in  M.  Louis's  valuable  paper,  On  the  Condition  of  the  Spinal 
Marrow  in  Cases  of  Caries  of  the  Vertebrae  ;*  and  I  will  relate  to  you 
another  still  more  remarkable  instance  of  it,  which  came  under  my  notice. 

1  M6moires,  ou  Recherches  Anatomico-Pathologiques,  8vo.,  Memoires  viii.  Observ.  i. 
p.  411.     Paris,  1826. 


CHRONIC   INFLAMMATION   OF   THE    SUBSTANCE   OF   THE   CORD.  129 

On  March  31, 1846,  a  little  girl,  aged  three  years  and  a  quarter,  the 
strumous  child  of  unhealthy  parents,  in  whose  family  phthisis  was 
hereditary,  was  brought  to  me  by  her  mother.  Nine  months  previously 
her  father  having  taken  her  in  his  arms  and  tossed  her,  she  suddenly 
cried  out  that  she  was  hurt,  and  for  several  days  afterwards  refused  to 
walk,  and  seemed  unable  to  stand,  sinking  down  on  her  hams  if  set  on 
her  feet.  She  made  no  definite  complaint,  however;  no  injury  was 
anywhere  observable,  and  in  about  three  weeks  she  seemed  to  have 
recovered  her  health,  and  continued  well  until  the  middle  of  March. 
At  that  time,  however,  her  frequent  complaints  of  pain  in  the  neck 
attracted  her  mother's  attention.  The  appearance  of  the  little  girl, 
when  first  placed  under  my  care,  was  very  remarkable ;  for  though  the 
face  wore  no  expression  of  suffering,  yet  the  neck  was  so  much  bent  as 
to  give  an  unusual  prominence  to  the  seventh  cervical  vertebra,  and  the 
head  was  constantly  directed  downwards.  No  part  of  the  spine  seemed 
particularly  tender ;  but  any  attempt  to  raise  the  head  was  forcibly 
resisted,  and  seemed  to  occasion  considerable  pain.  The  child  walked, 
though  with  a  tottering  gait,  and  if  left  alone  for  a  few  minutes  sank 
down  upon  her  knees  to  play.  Her  constant  complaint  was  of  being 
tired  and  drowsy,  notwithstanding  which  she  slept  ill ;  her  appetite  was 
bad,  and  her  bowels  were  constipated.  I  regarded  the  case  as  one  of 
incipient  disease  of  the  cervical  vertebrae,  and  was  anxious  to  make  an 
issue  in  the  back  of  the  neck,  but  the  parents  refused  to  consent  to  this 
proceeding.  Medical  treatment,  therefore,  was  confined  to  the  admin- 
istration of  the  cod-liver  oil,  and  afterwards  of  the  syrup  of  the  iodide 
of  iron ;  but  though  no  fresh  symptoms  appeared,  the  child  gradually 
lost  strength.  On  the  12th  of  May  she  was  able  to  walk  a  distance  of 
nearly  half  a  mile ;  but  on  the  14th,  though  not  worse  in  other  respects, 
she  was  unable  to  raise  her  hands,  and  was  forced  to  be  fed  by  another 
person.  In  the  evening  she  complained  of  her  eyes  aching,  but  never- 
theless slept  tolerably  well  till  1  A.  M.  She  then  awoke  crying  and 
fretful ;  but  on  being  taken  up  passed  an  evacuation,  and  on  lying  down 
again,  after  a  few  efforts  to  vomit,  which  soon  subsided,  spoke  a  few 
words  to  her  mother,  in  whose  arms  she  was  lying.  After  breathing 
in  a  sighing  manner  for  a  few  moments  she  seemed  to  fall  asleep,  and 
in  this  sleep  died  so  quietly,  that  her  mother  was  ignorant  of  it  until 
awakened  by  her  daughter's  corpse  beginning  to  grow  cold. 

On  examining  the  body  after  death  the  brain  was  found  to  be  quite 
healthy,  with  the  exception  of  some  venous  congestion  of  the  arachnoid. 
The  muscles  of  the  back  and  the  bones  of  the  spinal  column  were  per- 
fectly healthy  ;  but  on  laying  "open  the  vertebral  canal,  the  spinal  cord, 
from  a  level  with  the  third  down  to  the  seventh  cervical  vertebra,  bulged 
considerably,  so  as  completely  to  occupy  the  canal,  though  above  and 
below  this  its  size  was  natural. 

In  this  situation  the  two  layers  of  the  arachnoid  of  the  cord  were 
firmly  connected  together  by  numerous  filamentous  adhesions,  and  the 
membrane  itself  was  opaque  and  thickened. 

The  cord  in  the  situation  of  this  bulging  had  a  shining  gelatinous 
appearance,  not  unlike  turbid  and  badly  made  jelly,  with  a  yellowish 
lymph-like  matter  infiltrated  into  it.      This  softening  involved  the  pos- 

9 


130  INFANTILE   TRISMUS — ITS   SYMPTOMS. 

terior  columns  of  the  cord  much  more  than  the  anterior ;  the  bulging, 
too,  seemed  due  to  the  posterior  columns,  though  the  anterior  presented 
some  degree  of  softening. 

Three  apoplectic  effusions  were  discovered  in  the  spinal  cord.  The 
first  was  situated  just  below  the  calamus  scriptorius,  and  was  about  the 
size  of  a  lentil ;  the  nervous  matter  all  around  being  perfectly  healthy. 
The  second,  which  was  larger,  was  just  at  the  commencement  of  the 
swelling  of  the  cord,  and  partially  extended  into  the  sound  parts.  It 
just  shewed  through  the  surface  of  the  cord,  as  big  as  half  a  pea,  but 
on  longitudinally  dividing  the  cord,  was  seen  to  be  the  bigness  of  a 
kidney  bean ;  and  the  third  effusion,  just  above  the  termination  of  the 
swelling  of  the  cord,  was  about  as  large  as  a  big  pea.  Besides  these 
there  were  several  small  ecchymosed  spots  in  the  softened  parts  of  the 
cord,  but  all  the  effusions  of  blood  were  strictly  limited  to  the  posterior 
columns  of  the  cord. 

This  case  presents  many  points  of  interest.  The  scrofulous  diathesis  ^ 
in  the  family;  the  probable  injury  to  the  spine,  followed  for  a  short 
time,  by  impairment  of  the  motor  power ;  the  subsequent  occurrence  of 
pain  in  the  bended  neck,  and  the  fixed  position  of  the  head,  ail  seemed 
to  warrant  the  opinion  that  the  vertebrae  were  diseased  ;  but  all  resulted 
from  inflammatory  softening  of  the  spinal  cord,  while  the  bones  were 
perfectly  healthy.  The  softening  of  the  posterior  columns  of  the  cord, 
and  the  extravasation  of  blood  into  their  substance,  while  the  anterior 
columns  were  in  a  state  of  comparative  integrity,  are  occurrences  very 
remarkable  when  coupled  with  the  impaired  motor  power.1  Cases  such 
as  this  are  warnings  to  us  to  avoid  hasty  generalizations  on  physiolo- 
gical subjects;  they  show  us  how  hard  some  of  the  Sphinx's  riddles  are 
to  read. 

There  still  remains  one  affection  which  we  must  notice  in  connection 
with  the  disease  of  the  spinal  cord,  although  it  is  one  whose  pathology 
is  by  no  means  thoroughly  understood.  The  trismus  or  tetanus  of  new- 
born children  is  a  malady  which,  though  frequent  in  the  West  Indian 
Islands,  is  seldom  seen  in  this  country.  Four  instances  of  it  have  come 
under  my  own  notice,  three  of  which  occurred  in  the  Dublin  Lying-in 
Hospital,  while  for  the  opportunity  of  observing  the  fourth  I  am  indebted 
to  the  courtesy  of  Mr.  Stone,  of  Christ's  Hospital. 

The  disease  may  come  on  within  twelve  hours  after  birth,  or,  on  the 
other  hand,  may  not  occur  for  several  days ;  but  it  rarely  makes  its 
appearance  after  the  lapse  of  a  week.  I  once  saw  it  attack  a  child 
fifteen  hours  after  its  birth,  but  in  the  other  cases  it  came  on  upon 
the  fifth  day  in  one  instance,  and  the  sixth  in  the  other  two.  Though 
it  runs  a  rapid  course,  yet  its  onset  is  gradual ;  one  of  the  first 
things  that  attract  the  mother's  notice  being,  in  general,  that  the  child 
does  not  take  the  breast  when  put  to  it,  but  utters  a  whimpering  cry, 
and  if  the  mouth  be  then  examined  it  will  be  found  more  or  less  firm- 
ly fixed.  Sometimes  general  convulsions  come  on  suddenly,  and  usher  in 
the  other  symptoms,  but  they  more  frequently  follow  than  precede  the 

1  It  is  almost  impossible  in  so  young  a  subject  to  ascertain  accurately  the  state  of 
sensation,  but  there  was  no  obvious  indication  of  its  impairment  in  this  case. 


TRISMUS — ITS   PATHOLOGY   DOUBTFUL.  131 

trismus.  When  fully  developed,  these  fits,  which  come  on  in  paroxysms, 
are  ushered  in  by  a  screech,  or  attended  with  some  impairment  of  the 
respiration,  and  during  their  continuance  the  whole  surface  becomes  livid. 
The  hands  are  strongly  clenched,  the  feet  forcibly  flexed  on  the  ankles, 
and  the  toes  bent,  and  remain  so  during  the  fit,  while  the  trunk  is  curved 
backwards  in  a  condition  of  opisthotonos :  the  mouth  is  generally 
drawn  slightly  open,  and  the  lower  jaw  firmly  fixed.  When  the  fit 
subsides,  the  muscles  do  not  become  generally  relaxed,  but  the  child 
still  lies  with  its  hands  clenched,  and  its  thumbs  drawn  into  the  palm, 
the  legs  being  generally  crossed,  and  the  great  toe  separated  widely 
from  the  others,  while  the  head  is  thrown  back,  and  the  opisthotonos 
continues,  though  in  a  diminished  degree.  The  condition  of  the  mouth 
is  peculiar  and  characteristic.  The  jaws  at  first  are  slightly  open, 
and  the  corners  of  the  mouth  drawn  downwards  and  backwards,  but  as 
the  disease  advances  the  jaws  become  quite  closed,  the  corners  of  the 
mouth  even  more  drawn  down,  and  the  lips  firmly  compressed  against 
the  gums.  The  power  of  suckingis  early  lost,  but  for  some  time  the  clild 
continues  able  to  swallow ;  at  length,  however,  it  accomplishes  this 
with  great  difficulty,  a  convulsion  sometimes  following  the  attempt, 
while  even  that  fluid  which  had  apparently  been  swallowed  is  for  the 
most  part  speedily  regurgitated.  The  child  dies  either  during  some 
paroxysm  of  convulsions,  or,  seeming  much  exhausted,  it  sinks  into  a 
comatose  condition,  and  so  expires.  There  are  few  affections  that  run 
so  fearfully  rapid  a  course  as  this ;  its  fatal  termination  almost  always 
taking  place  within  thirty-six,  often  within  twenty-four  hours  from  the 
appearance  of  the  first  symptoms. 

The  most  frequent  post-mortem  appearance  in  these  cases,  and  that 
which  I  found  in  the  bodies  of  all  the  four  children  whom  I  observed, 
consists  of  effusion  of  blood,  either  fluid  or  coagulated,  into  the  cellular 
tissue  surrounding  the  theca  of  the  cord.  Conjoined  with  this  there  is 
generally  a  congested  state  of  the  vessels  of  the  spinal  arachnoid,  and 
sometimes  an  effusion  of  blood  or  serum  into  its  cavity.  The  signs  of 
congestion  about  the  head  are  less  constant,  though  much  oftener 
present  than  absent,  and  sometimes  existing  in  an  extreme  degree, 
while  in  one  instance,  I  found  not  merely  a  highly  congested  state  of 
the  cerebral  vessels,  but  also  an  effusion  of  blood  in  considerable  quan- 
tity between  the  skull  and  dura  mater,  and  also  a  slighter  effusion  into 
the  arachnoid  cavity. 

In  spite,  however,  of  the  striking  nature  of  these  morbid  appear- 
ances, I  formerly  hesitated  in  referring  the  symptoms  of  trismus  with 
certainty  to  this  apoplectic  condition  of  the  cord.  My  hesitation  arose 
from  the  circumstance  that  on  examining  some  years  ago  the  bodies  of 
infants  who  died  soon  after  birth  in  the  Dublin  Lying-in  Hospital,  I 
very  frequently  found  great  fullness  of  the  vessels  of  the  cord,  and  a 
gelatinous  matter,  which  was  frequently  deeply  tinged  with  blood, 
effused  around  its  theca.  It  therefore  became  a  question  whether 
appearances  such  as  are  met  with  in  cases  of  trismus  might  not 
in  reality  be  due  to  the  position  in  which  the  bodies  had  been  allowed 
to  remain,  resting  on  the  back,  and  be  rather  the  result  of  simple 
gravitation,  than  the  consequences  of  the  disease.     These  doubts  how- 


132  CASES   OF  TRISMUS. 

ever,  have  been  set  at  rest  by  the  very  excellent  observations  of  Dr. 
Weber,  of  Kiel,1  who  placed  the  bodies  of  infants  in  various  positions 
before  examining  them,  and  thus  was  able  to  descriminate  between 
morbid  and  pseudo-morbid  appearances,  and  who,  moreover,  although 
he  on  every  occasion  placed  children  who  had  died  of  trismus  upon 
their  face  immediately  after  death,  yet  found  on  every  occasion  intense 
injection  of  the  minute  vessels  of  the  cord  and  its  membranes,  extrava- 
sation of  blood  external  to  the  theca,  and  other  appearances  similar  to 
those  which  I  have  just  described  to  you. 

There  are  few  diseases  respecting  the  cause  of  which  opinions  so 
various  have  prevailed  as  with  regard  to  trismus.  Bearing  in  mind  the 
frequency  of  external  injury  as  a  cause  of  locked-jaw  in  the  adult,  some 
writers  have  sought  to  find  in  every  case  the  history  of  some  blow  or 
other  injury  to  which  it  might  possibly  be  attributed,  while  others  have 
conceived  that  it  depended  on  awkward  management  of  the  navel- 
string,  or  injury  of  some  kind  or  other  inflicted  on  it.  This  last  opinion 
has  appeared  to  derive  support  from  some  cases  in  which  the  umbilical 
vein  has  presented  the  signs  of  phlebitis :  but  further  observation  has 
shewn  these  appearances  to  be  anything  but  constant,  and  though 
carefully  sought  for,  they  were  not  found  in  any  of  the  cases  which 
came  under  my  notice.  Moreover,  a  German  physician,  Dr.  Mildner, 
of  Prague,2  who  has  recorded  the  results  of  46  cases  of  fatal  inflamma- 
tion of  the  umbilical  vessels  in  children  born  in  the  Lying-in  Hospital 
in  that  city,  states  that  convulsions  occurred  in  only  5  of  the  number, 
and  that  in  no  instance  had  these  convulsions  the  least  resemblance  to 
those  which  characterise  trismus.  Congestion  of  the  liver,  impairment 
of  its  functions,  and  icterus,  were  among  the  symptoms  which  attended 
it,  as  well  as,  in  many  of  the  cases,  peritonitis,  inflammation  of  the 
abdominal  integuments,  purulent  injection  of  the  blood,  and  the  forma- 
tion of  abscesses  in  the  joints,  which  occurred  33  times,  while  in  4 
cases  haemorrhage  took  place  from  the  umbilicus.  We  may,  then, 
fairly  conclude  that  the  connection  between  this  disease  and  trismus  is 
merely  an  accidental  coincidence. 

The  remarkable  frequency  of  the  disease  in  hot  climates,  where  the 
heat  of  the  day  is  succeeded  by  intense  cold  at  night,  favours  the 
opinion  that  interruption  of  the  function  of  the  skin,  by  sudden  alter- 
nations of  temperature,  is  a  powerful  cause  of  the  disease.  In  an 
epidemic  of  this  disease  in  the  Lying-in  Hospital  at  Stockholm,  in 
1834,3  there  seemed  also  to  be  a  most  marked  connection  between  the 
periods  of  its  greatest  prevalence  and  the  fluctuations  of  temperature. 
Nothing,  however,  can  be  more  satisfactorily  proved,  than  the  tendency 
of  a  vitiated  state  of  atmosphere  to  produce  it.  Where  such  a  condi- 
tion exists,  there  trismus  abounds,  be  the  peculiarities  of  climate  or 
temperature  what  they  may.  It  is  very  frequent  among  the  children 
of  the  negroes  in  the  slave  states  of  America :  it  is  depopulating  the 
island  of  St.  Kilda,  and  64  per  cent,  of  the  infants  born  in  Wcst- 

1  Beitr'age  zur  pathologischen  Anatomie  der  Neugebornen,  8vo.  part  i.  pp.  6,  63,  and 
73.     Kiel,  1851. 

2  Prager  Vierteljahrschr.  v.  2.  1848;  and  Schmidt's  Jahrb.  No.  7,  p.  64,  1848. 

3  Cederscbjoid,  in  Buscb's  Zeitschrift  far  Geburtsk,  x.  345. 


CAUSES   AND   TREATMENT   OP  TRISMUS.  133 

manno,  a  small  islet  off  the  coast  of  Iceland,  die  of  it  between  the  5th 
and  12th  day  from  birth.1  Dirt,  and  defective  ventilation,  are  probably 
almost  the  only  points  in  common  between  the  dwellers  in  the  southern 
states  of  the  Union  and  the  inhabitants  of  Northern  Europe  and  the 
Arctic  Regions.  But,  if  any  further  proof  were  needed  that  to  this 
cause,  and  not  to  some  fancied  displacement  of  the  cranial  bones,3  this 
disease  is  really  to  be  attributed,  we  are  furnished  with  it  in  the 
records  of  the  Dublin  Lying-in  Hospital,  which  point  out  both  the  evil 
and  its  remedy.  Sixty  years  ago,  every  sixth  child  born  in  that 
institution  died  within  a  fortnight  after  birth,  and  trismus  was  the 
cause  of  the  death  of  ||  of  these  children.  Dr.  Joseph  Clarke  adopted 
means  to  secure  the  efficient  ventilation  of  the  hospital,  and  the 
mortality  of  the  children  fell  at  once  to  1  in  19J ;  and  during  Dr. 
Collins's  mastership,  from  1826  to  1833,  was  only  1  in  98|,  and  but 
little  more  than  the  ninth  part  of  that  mortality  depended  on  trismus.3 
But  though  we  may  hope  by  wise  hygienic  measures  to  avert  this 
disease,  yet,  when  once  it  has  become  developed,  our  prospects  of  cure 
are  so  slender  that  I  may  almost  say  the  task  is  hopeless.  I  have  not 
seen  leeches  employed,  but,  bearing  in  mind  the  post-mortem  appear- 
ances, should  certainly  be  disposed  to  apply  them  freely  at  the  outset 
of  the  disease.  I  have  seen  the  hot  bath  used  with  temporary  relief ; 
but  though  I  have  witnessed  the  employment  of  calomel  and  of  anti- 
spasmodics, as  assafoetida,  and  the  administration  of  an  enema  of  gr. 
iij.  of  tobacco  infused  for  half  an  hour  in  ^viij.  of  water,  yet  I  have 
never  known  any  of  these  means  followed  by  even  a  temporary  pause 
in  the  symptoms ;  and  the  endeavour  to  excite  the  action  of  the  skin  is 
the  only  measure  that  in  the  cases  which  I  witnessed  seemed  to  be  of 
the  slightest  service. 


LECTURE    XII. 

Night  Terrors — usually  depend  on  intestinal  disorder,  not  on  primary  disease  of  the 
brain — their  symptoms  not  to  be  mistaken  for  those  of  incipient  hydrocephalus — 
— sometimes  continue  to  occur  for  many  weeks — Treatment. 

Epilepsy — a  disease  of  youth  rather  than  of  childhood — frequently  recurring  convul- 
sions in  childhood  never  to  be  neglected. 

Chorea — often  connected  with  disorders  of  approaching  puberty — not  peculiar  to 
childhood — principles  of  treatment — Partial  chorea. 

Paralysis — sometimes  congenital — often  follows  very  slight  and  temporary  symptoms 
of  cerebral  disturbance — most  frequent  during  process  of  dentition — Recovery  very 
uncertain — great  importance  of  early  treatment — serious  results  of  its  remaining 
uncured — Diagnosis — Treatment. 

Facial  Hemiplegia  in  new-born  infants. 

We  have  now  nearly  completed  our  examination  of  the  disease  of  the 
brain  and  spinal  cord  in  childhood,  but  there  are  some  affections  of  the 

1  See  a  very  interesting  notice,  in  the  British  and  Foreign  Medico-Chirurgical  Review 
for  April  1850,  of  a  work  by  Dr.  Schleisner  on  the  Sanitary  Condition  of  Iceland. 

2  A  theory  prepounded  by  Dr.  Sims,  of  Alabama,  in  the  American  Journal  of  the 
Medical  Sciences  for  1846,  and  further  expanded  in  the  same  journal  for  July  and 
October  1848. 

3  Collins's  Treatise  on  Midwifery,  p.  513. 


134  NIGHT   TERRORS. 

nervous  system  which  are  often  independent  of  any  change  in  the 
nervous  centres  such  as  our  means  of  anatomical  investigation  can 
discover,  or  which  are  but  the  expression  of  the  sympathy  of  the  brain 
and  spinal  cord  with  the  sufferings  of  some  distant  organ.  To  their  brief 
study  we  must  devote  the  present  hour. 

It  happens  sometimes  that  a  child  who  has  gone  to  bed  apparently 
well,  and  has  slept  soundly  for  a  short  time,  awakes  suddenly  in  great 
terror,  and  with  a  loud  and  piercing  cry.  The  child  will  be  found 
sitting  up  in  its  bed,  crying  out,  as  if  in  an  agony  or  fear,  "  Oh  dear ! 
oh  dear  !  take  it  away  !  father!  mother  !"  while  terror  is  depicted  on 
its  countenance,  and  it  does  not  recognize  its  parents,  who  alarmed  by 
the  shriek  have  come  into  its  room,  but  seems  wholly  occupied  with  the 
fearful  impression  that  has  aroused  it  from  sleep.  By  degrees  con- 
sciousness returns,  the  child  now  clings  to  its  mother  or  its  nurse, 
sometimes  wants  to  be  taken  up  and  carried  about  the  room,  and,  by 
degrees,  sometimes  in  ten  minutes,  sometimes  in  half  an  hour,  it  grows 
quiet,  and  again  falls  asleep.  As  the  terror  abates,  the  child  in  some 
instances  grows  quiet  at  once,  but  frequently  it  bursts  into  a  fit  of 
passionate  weeping  and  sobs  itself  to  rest  in  its  mother's  arms.  In 
some  instances  a  quantity  of  limpid  urine  is  voided  as  the  fit  passes 
off;  but  this  occurrence  is  by  no  means  constant.  Usually  the  remainder 
of  the  night  is  passed  in  tolerably  sound  sleep,  and  the  following  night 
the  child  may  rest  quite  undisturbed,  or  the  terrors  may  again  return, 
and  with  precisely  the  same  symptoms  as  before.  The  attack  usually 
comes  on  after  the  child  has  been  from  half  an  hour  to  a  couple  of 
hours  asleep ;  and  two  attacks  do  not  generally  occur  in  the  same  night. 
They  are  always  more  or  less  distinctly  associated  with  the  impression 
of  some  object  which  occasions  alarm, — as  a  cat  or  dog,  which  is 
fancied  to  be  on  the  bed ;  and  this  illusion  continues  even  after  the 
child  has  recognized  those  who  are  around  it.  The  condition  is  not 
one  of  delirium,  for  the  child  has  no  other  hallucinations,  but  the  attack 
may  return  night  after  night  with  precisely  the  same  characters.  The 
previous  sleep  sometimes  seems  sound,  and  though  often  uneasy,  yet 
talking  in  the  sleep  does  not  usually  occur,  and  after  the  child  has  been 
pacified  it  generally  sleeps  heavily,  perhaps  till  morning,  or  till  a 
second,  usually  slighter  attack  comes  on  ;  but  this  scarcely  ever  occurs 
until  after  sleep  has  again  lasted  for  an  hour  or  longer. 

Seizures  of  this  kind  may  come  on  under  a  great  variety  of  circum- 
stances and,  according  to  the  cause  whence  they  have  arisen,  may 
continue  to  return  for  many  weeks  together,  or  may  occur  but  a  few 
times.  As  far  as  I  have  had  the  opportunity  of  judging,  they  are  never 
the  indications  of  primary  mischief  in  the  brain,  but  are  always  asso- 
ciated with  some  disturbance  of  the  intestinal  canal,  and  more  or  less 
obvious  gastric  disorder. 

A  few  months  ago  I  saw  a  little  boy,  aged  11  months,  in  whom  the 
process  of  dentition  was  just  beginning,  and  who  for  ten  days  had  had 
slight  diarrhoea,  with  dark  and  slimy  evacuations.  He  then  awoke  one 
night,  though  before  apparently  sleeping  soundly,  with  a  sudden  start, 
and  a  scream  so  violent  that  all  the  people  in  the  house  heard  it.  When, 
taken  out  of  bed  he  continued  crying  loudly  for  some  minutes,  but  by 


SYMPTOMS   USUALLY  DEPEND   ON   INTESTINAL   DISORDER —  135 

degrees  grew  quiet  and  fell  asleep  again,  sweating  profusely.  This 
sleep  was  as  heavy  as  it  had  been  before,  though  the  eyes  were  not 
always  closed  during  it,  but  after  an  uncertain  interval  of  from  half  an 
hour  to  two  hours  he  would  again  awake  with  the  same  loud  and  ter- 
rified scream,  and  again  in  a-  few  minutes  sink  into  a  slumber.  The  first 
of  these  attacks  had  taken  place  six  days  before  the  child  was  brought 
to  me :  they  were  increasing  in  frequency,  as  many  as  seven  or  eight 
having  occurred  in  the  course  of  a  single  night,  and  even  during  his 
sleep  in  the  day  time  the  child  was  not  free  from  them.  He  was 
cheerful,  however,  at  other  times ;  he  sucked  well,  did  not  vomit,  his 
head  was  not  hot,  and  the  anterior  fontanelle  was  depressed  rather  than 
prominent ;  but  the  abdomen  was  rather  full,  and  somewhat  tender  ; 
the  gums  were  much  swollen,  and  the  tongue  rather  furred. 

The  gums  were  lanced,  the  child  was  put  in  a  tepid  bath  every  night : 
a  powder  containing  one  grain  of  Hydr.  c.  Cretan,  and  one  of  Dover's 
powder,  was  given  daily  at  bed-time,  and  3j.  of  castor  oil  every  morning, 
and  the  attacks  subsided. 

Cases  of  this  kind  illustrate  a  point  of  practice,  which,  though  impor- 
tant in  the  adult  (you  will  find  it  insisted  on  by  Andral  in  his  Clinique 
Medicale)  is  still  more  so  in  the  child.  It  is,  that  in  many  affections  of 
the  brain  there  is  a  stage  quite  at  the  commencement  in  which  depletion 
may  be  out  of  place,  but  opiates  or  sedatives  will  allay  the  irritation, 
which,  if  left  alone,  would  issue  in  dangerous  or  fatal  congestion,  or 
inflammation. 

In  the  majority  of  cases  of  these  night  terrors  the  condition  of  the 
bowels  is  one  of  constipation,  not  of  diarrhoea.  Sometimes,  after  gastric 
disorder  has  continued  for  a  few  days,  in  the  course  of  which  perhaps 
vomiting  may  have  occurred,  an  attack  of  this  nocturnal  alarm  may 
throw  the  parents  into  a  state  of  great  apprehension  lest  hydrocephalus 
should  be  impending.  I  have  seen  a  very  severe  attack  of  jaundice 
come  on  with  these  symptoms ;  and  in  such  a  case  it  is  important  to 
bear  in  mind  the  difference  between  the  sudden,  sympathetic  disturbance 
of  the  brain,  and  the  more  gradual  aproach  of  hydrocephalus,  with  the 
drowsiness  the  child  experiences,  and  yet  the  difficulty  it  has  in  going 
to  sleep,  the  restlessness  all  night  long,  or  the  unquiet  slumber,  with 
the  moaning  and  starting  which  I  pointed  out  to  you  when  speaking  of 
that  disease.  If,  then,  bearing  in  mind  these  facts,  you  find  that  the 
child  who  has  had  this  attack  in  the  night  yet  does  not  complain  of 
intolerance  of  light,  or  of  much  or  any  headache,  and  that  while  the 
head  is  cool  and  the  pulse  regular,  the  abdomen  is  full  and  hard,  and 
perhaps  slightly  tender,  you  will  scarcely  take  the  less  for  the  more 
dangerous  affection. 

But  these  symptoms  may  last  for  weeks  or  months  together,  neither 
diminishing  or  much  increasing  in  severity,  so  that  they  seem  almost 
to  constitute  an  independent  disease :  a  view  which  Dr.  Hesse  of 
Altona,1  who  has  written  a  very  good  pamphlet  on  it,  is  disposed  to 
take  somewhat  too  generally. 

Such  a  case  was  that  of  a  delicate  boy,  7  years  old,  who  during  the 
previous   twelve  months,  had  been  cutting  his  first  permanent  molar 

1  Ueber  das  n'achtliche  Aufschrecken  der  Kinder  im  Schlafe.     8vo.  Altenburg,  1845. 


136  '  _  NOT   ON   PRIMARY  DISEASE   OP   THE   BRAIN. 

teeth,  and  for  the  whole  of  that  time  had  suffered  from  attacks  of  night 
terrors,  which  usually  came  on  about  half  an  hour  after  he  had  fallen 
asleep.  He  then  started  up  with  a  wild  and  terrified  look,  and  loud 
outcries,  appearing  not  to  know  any  one  for  some  time,  then  begging 
to  be  taken  up,  and  becoming  pacified  after  being  carried  about  for  half 
an  hour  in  his  father's  arms.  As  the  seizure  passed  off  he  used  to  void 
a  large  quantity  of  limpid  urine,  and  having  fallen  asleep  again,  never 
but  once  had  a  second  attack  of  it  in  the  same  night,  while  sometimes 
none  occurred  for  two  or  three  nights  together.  In  other  respects  he 
seemed  to  be  tolerably  well,  and  was  a  lively  and  intelligent  child, 
though  for  about  fourteen  days  before  he  was  brought  to  me  his  health 
had  appeared  less  good,  and  there  were  evident  indications  of  gastric 
disorder.  I  never  saw  this  child  but  once  again,  so  I  cannot  tell  you 
his  subsequent  history  ;  but  his  case  affords  a  good  illustration  of  the 
occasional  persistence  of  these  symptoms  for  a  long  time  without  the 
supervention  of  any  really  serious  disease. 

Although  these  symptoms  may  be  the  result  of  sympathetic  affection 
of  the  brain  through  the  medium  of  the  abdominal  viscera,  still  you 
should  watch  a  child  in  whom  they  had  frequently  occurred  with 
especial  care,  knowing  that  long-continued  irritation  of  the  nervous 
centres  may,  under  the  influence  of  comparatively  trivial  causes,  issue 
in  serious  disease.  Your  chief  attention,  however,  must  be  directed  to 
the  removal  of  the  disorder  of  the  intestinal  canal ;  and  this  should  be 
attempted  by  gentle  means, — by  the  careful  regulation  of  the  diet,  and 
the  judicious  combination  of  aperients  and  tonics,  rather  than  by 
drastic  purgatives.  At  the  same  time,  too,  it  is  right  that  the  child 
should  not  be  left  in  the  dark,  or  alone :  the  affection  resembles  night- 
mare, and  in  childhood  dream-images  seem  to  mingle  with  the  waking 
impressions  much  more  than  in  adult  age.  A  light  burning  brightly 
in  the  room,  and  a  familiar  face  meeting  the  child's  eye  at  once  on 
awaking,  will  do  much  towards  breaking  the  spell,  and  towards  allaying 
its  fears.  Harshness  in  such  cases  is  quite  out  of  place,  and  few  pieces 
of  cruelty  can  be  greater  than  forcing  a  timid  little  child,  in  whom 
threatenings  of  these  attacks  have  occurred,  to  go  to  bed  in  the  dark,  or 
to  lie  there  without  a  candle,  while  its  active  imagination  conjures  up 
before  its  eyes  out  of  the  bed-curtains,  or  other  objects  in  the  room, 
the  outlines  of  all  sorts  of  terrific  forms. 

But  occurrences  much  more  alarming  may  take  place  independent  of 
any  primary  disease  of  the  nervous  centres.  Convulsions  may  come 
on;  and  these  convulsions  may  occur  again  and  again  until  the  patient 
dies,  and  yet  we  may  find  few  or  no  morbid  appearances  in  the  brain  or 
the  spinal  cord  to  account  for  their  occurrence.  I  shall  not,  however,  say 
more  on  this  subject  now,  for  I  explained  to  you  some  time  since  that, 
in  the  great  majority  of  instances,  such  attacks  of  convulsions  depend 
on  a  state  of  temporary  congestion  of  the  brain  produced  in  some 
indirect  way.  Any  other  remarks  that  it  may  be  desirable  to  make 
upon  them  will  be  most  in  place  when  I  speak  of  the  different  diseases 
in  the  course  of  which  they  are  likely  to  occur. 

When  general  convulsions  continue  to  recur  at  intervals,  and  without 
any  very  evident  cause,  for  weeks  or  months  together,  the  affection 


EPILEPSY.  137 

then  receives  the  name  of  epilepsy.  Epilepsy  is  a  disease  of  all  ages ; 
its  foundation  may  even  be  laid  in  early  infancy,  and  the  fits  may  con- 
tinue to  recur  up  to  adult  age ;  though  my  own  experience  leads  me  to 
believe  that  this  is  an  exceptional  occurrence,  and  that  the  history  of 
epilepsy  comparatively  seldom  dates  back  to  a  period  prior  to  the 
second  dentition.  It  seems,  indeed,  to  be  less  one  of  the  diseases  of 
childhood,  than  of  that  period  of  youth  during  which  the  great  changes 
that  are  accomplished  at  puberty  are  preparing  or  being  carried  out. 
In  fact,  it  was  but  seldom  that  I  saw  cases  of  epilepsy  at  the  Children's 
Infirmary ;  and,  in  the  few  instances  where  I  met  with  it,  it  was  usually 
traceable  either  to  a  fall,  or  a  blow  on  the  head,  or  to  fright.  Terror 
I  believe  to  be  by  no  means  an  infrequent  exciting  cause  of  epileptic 
seizures  in  childhood.  A  little  girl,  10  years  old,  was  some  time  since 
under  my  care,  who,  I  fear,  became  permanently  epileptic,  and  whose 
first  fit  was  induced  by  this  cause.  She  was  at  home,  in  the  same  room 
with  her  parents,  when  a  quarrel  arose  between  them,  and  her  father 
struck  her  mother.  The  child  in  terror  ran  into  the  street,  and  was 
picked  up  in  a  fit.  After  this  had  passed  off  she  continued  well  for  five 
clays ;  but  another  fit  then  came  on  while  she  was  at  Sunday  school, 
and  was  followed  on  the  succeeding  day  by  a  third.  For  fourteen  days 
the  fits  recurred  daily,  and  sometimes  two  or  three  in  a  day.  They 
then  grew  less  frequent ;  but  at  the  end  of  six  weeks  still  came  on  once 
or  twice  a  week.  Whether  they  eventually- ceased  entirely  I  do  not 
know,  but  much  fear  the  contrary. 

The  sight  of  another  person  in  a  paroxysm  of  epilepsy  has  been 
mentioned  by  many  writers  as  peculiarly  likely  to  give  rise  to  its  occur- 
rence. Some  time  since,  I  had  the  painful  task  of  watching  the  gradual 
blunting  of  all  the  mental  powers  in  a  fine  boy,  between  13  and  14 
years  old,  who  had  been  epileptic  since  his  fifth  year.  Down  to  that 
time  he  had  had  no  cerebral  affection ;  but  then,  while  weak  from  a 
recent  attack  of  remittent  fever,  he  saw  his  elder  brother  fall  down  in  a 
fit  of  convulsions.  This  so  frightened  the  child  that  he  was  immediately 
seized  with  violent  convulsions,  which  lasted  for  twelve  hours.  Con- 
sciousness was  restored  only  after  very  copious  depletion  and  other 
active  remedies ;  but  he  remained  an  epileptic  for  life,  and  when  I  last 
saw  him  was  fast  sinking  into  a  state  of  idiocy. 

Hereditary  tendency  to  epilepsy  seems  to  be  a  very  frequent  cause 
of  its  occurrence  early  in  life  ;  but  besides  this,  there  seem  to  be  few  so 
powerful  as  the  practice  of  masturbation,  to  which,  unhappily,  children 
sometimes  become  addicted  long  before  puberty. 

Fits  may  occur  in'  children,  and  return  at  intervals,  even  for  several 
weeks,  owing  to  the  irritation  of  ascarides  in  the  intestines.  In  such 
cases,  however,  you  would  generally  have  good  evidence  of  the  presence 
of  the  entozoa :  and  you  would  find  the  fits  permanently  subside  on 
obtaining  their  complete  expulsion. 

I  do  not  know  that  there  are  any  points  which  call  for  your  special 
attention  in  the  treatment  of  epilepsy  during  childhood.  You  must  look 
on  the  frequent  recurrence  of  convulsions  in  early  life  as  of  the  greatest 
moment,  and  must  not  allow  yourselves  to  be  seduced  into  inertness  in 
their  treatment,  by  the  hope,  which  you  will  generally  find  a  very  mis- 


138  CHOREA. 

taken  one,  that  they  will  cease  with  the  changes  in  the  system  that 
puberty  brings  with  it. 

There  is  a  form  of  partial  convulsion,  in  which,  while  the  consciousness 
is  unimpaired,  and  the  muscles  to  a  certain  extent  obey  the  will,  they  do 
not  completely  so,  but  some  of  them  are  in  a  state  of  almost  constant 
involuntary  movement.  With  this  affection,  Chorea,  or  St.  Vitus' s  dance 
as  it  is  called,  you  are  doubtless  acquainted.  Though  more  frequent 
before  puberty  than  afterwards,  it  is  by  no  means  of  common  occurrence  ; 
but  it  certainly  is  not  so  rare,  as  I  judged  merely  from  my  own  ex- 
perience at  the  Children's  Infirmary,  where  I  did  not  meet  with  it  in 
above  1  out  of  1000  cases,  I  might  conclude  it  to  be.  Sydenham,  and 
other  writers  of  his  day,  supposed  that  it  was  almost  peculiar  to  the 
period  shortly  preceding  puberty,  and  the  circumstance  that  it  attacks 
girls  almost  thrice  as  often  as  it  does  boys,  seems  to  favour  the  supposi- 
tion that  it  depends  on  some  interruption  of  the  great  processes  which 
ought  at  that  time  to  take  place  in  the  organism.  And  it  unquestionably 
does  so  in  many  instances,  though  by  no  means  so  constantly  as  was 
once  supposed ;  for,  on  a  comparison  of  a  large  number  of  cases,  we  find 
that  it  occurs  nearly  as  frequently  between  the  ages  of  six  and  ten  years, 
as  between  the  latter  date  and  the  period  of  puberty.  The  predominance 
of  females  over  males,  among  those  who  are  attacked  by  it,  though 
especially  marked  in  chorea,  is  observed  in  the  case  of  many  of  the  non- 
inflammatory affections  of  the  nervous  system  in  childhood  as  well  as  in 
adult  life. 

When  chorea  does  not  come  on  in  connection  with  that  derangement 
of  the  general  health  which  often  precedes  puberty,  a  sudden  fright 
seems  to  be  one  of  its  most  frequent  exciting  causes.  At  other  times 
it  appears  to  be  connected  with  a  state  of  intestinal  disorder,  or  with 
some  irregularity  in  the  progress  of  the  second  dentition ;  while  occa- 
sionally we  cannot  detect  any  signs  of  disease  to  which  the  involuntary 
muscular  movements  may  be  attributed.  In  some  few  instances  of 
organic  disease  of  the  brain  or  spinal  cord,  involuntary  movements 
have  been  noticed  like  those  of  chorea ;  and  you  are  doubtless  aware 
of  the  connection  that  has  now  and  then  been  observed  between  chorea 
and  pericarditis. 

The  study  of  all  points  connected  with  this  disease  would  bring  before 
us  many  questions  of  physiological  and  pathological  interest,  but  at 
the  same  time  would  lead  us  away  from  the  special  object  of  these  lec- 
tures, which  is,  the  investigation  of  diseases  that  are  either  peculiar  to 
childhood,  or  which  undergo  important  modifications  when  they  occur 
during  early  life. 

For  this  reason  it  is  that  I  have  noticed  this  affection  so  briefly,  and 
that  I  shall  be  equally  short  in  speaking  of  its  treatment.  In  the  great 
majority  of  cases  purgatives  are  indicated  not  only  at  the  commencement 
but  throughout  the  course  of  the  disease,  the  bowels  having  a  great  ten- 
dency to  become  constipated,  even  though  the  functions  of  the  diges- 
tive organs  be  not  otherwise  disordered.  At  the  outset  it  is  often 
necessary  to  administer  the  more  active  purgatives,  such  asscammony; 
but  you  will,  I  think,  find  that  the  due  action  of  the  bowels  is  better 
secured  by  some  of  the  warmer  aperients,    such  as  aloes,  which,  though 


PARTIAL  CHOREA.  139 

so  bitter,  is  generally  readily  taken  by  children,  since,  owing  to  its  small 
bulk,  it  can  be  very  well  given  in  a  little  coarse  sugar  or  treacle.  Tonics 
most  generally  go  hand  in  hand  with  aperients  ;  and  by  common  con- 
sent the  ferruginous  preparations  are  regarded  as  of  peculiar  value  in 
this  affection.  Though  much  has  been  said  about  the  virtues  of  the 
carbonate  of  iron,  I  do  not  apprehend  that  any  one  preparation  has  a 
decided  superiority  over  others  ;  but  having  continued  one  for  a  time,  it 
will  usually  be  desirable  to  substitute  for  it  another  form  of  the  remedy. 
The  cold  shower  bath  is  a  tonic  often  of  remarkable  service  in  this  dis- 
ease. Its  use,  however,  must  be  begun  with  care ;  the  child  must  not 
be  frightened  by  being  subjected  all  at  once  to  too  copious  or  too  cold 
an  affusion,  but  if  you  begin  with  but  a  small  quantity  of  water,  and 
that  tepid,  you  will  generally  be  able  in  the  course  of  a  few  days  to 
employ  the  bath  in  such  a  manner  as  shall  be  really  efficacious. 

Of  course,  while  you  are  pursuing  this  tonic  plan  of  treatment,  the 
general  management  of  the  child  must  be  in  harmony  with  it.  Residence 
in  the  country,  sea-air  and  sea-bathing,  a  well-regulated  but  nutritious 
diet,  from  which  even  wine  is  not  always  to  be  excluded,  will,  when  com- 
bined with  the  avoidance  of  over-excitement  in  any  form,  often  do  as 
much  as  medicine,  or  even  more,  for  the  restoration  of  your  patient. 

In  the  great  majority  of  cases  of  chorea  you  may  assure  the  friends 
of  your  patient  that  the  disease  will  ultimately  subside,  though  it  may 
last  for  several  weeks.  You  cannot  however,  speak  with  the  same  con- 
fidence, with  reference  to  a  kind  of  partial  chorea  that  you  will  occa- 
sionally meet  with,  and  in  which  some  muscles  only  are  affected. 

A  few  years  ago,  I  saw  a  young  lady,  nine  years  old,  whose  health 
had  never  been  robust,  and  who  had  often  suffered  from  headache  and  gas- 
tric disorder.  When  seven  years  of  age,  she  began,  without  any  special 
cause,  to  have  frequent  twitchings  of  the  muscles  of  the  face ;  and  almost 
ever  since,  some  muscles,  either  of  the  face,  neck,  mouth,  or  extremities, 
had  been  similarly  affected,  though  it  had  scarcely  ever  happened  that 
two  sets  of  muscles  were  thus  disturbed  at  the  same  time.  She  had 
been  under  the  care  of  several  practitioners,  and  by  some  had  been 
leeched  and  mercurialized  with  manifest  disadvantage.  Some  benefit 
had  been  derived  from  large  doses  of  carbonate  of  iron,  and,  when  in  the 
country  during  the  summer  before  I  saw  her,  the  involuntary  movements 
had  almost  entirely  ceased.  She  had  not  long  returned  home  however, 
when  a  slight  twitching  began  about  the  muscles  of  the  lower  jaw;  but 
this  ceased  in  a  few  weeks,  and,  instead  of  it,  there  was  now  a  convul- 
sive twitching  of  the  head  towards  one  or  other  shoulder.  A  month 
afterwards  she  began  to  have  occasional  contractions  of  the  muscles  of 
the  right  hand,  so  that  the  pen  would  drop  from  her  hand  while  writing, 
and  the  fingers  would  be  gathered  up  into  the  hand.  On  the  last  time 
that  I  saw  her,  the  contraction  of  the  fingers  had  ceased  to  occur  ;  the 
spasmodic  movement  of  the  neck  was  much  less  frequent,  and  was  slight- 
er, but  there  were  slight  movements  of  the  back.  This  child's  bowels 
had  been  disordered  and  constipated,  and  her  general  condition  was 
weakly.  I  regulated  the  bowels,  gave  the  ferro-citrate  of  quinine,  and 
afterwards  other  preparations  of  iron,  and  when  the  spring  came  on,  sent 
her  into  the  country,  where,  as  I  afterwards  heard,  she  became  quite 
well. 


140  PARALYSIS — SOMETIMES   CONGENITAL. 

The  danger  in  these  cases,  and  one  which  you  cannot  even  with  the 
most  judicious  management  always  guard  against,  is,  lest  some  one  or 
two  muscles  should  become  permanently  affected  by  this  spasmodic 
movement — an  occurrence  which,  though  not  otherwise  of  importance,  is 
very  distressing  if  that  patient  be  a  female. 

Disturbance  of  the  nervous  system  shews  itself  in  children  as  well  by 
loss  of  the  motor  power  as  by  the  occurrence  of  involuntary  movements  ; 
and  such  an  accident  as  the  palsy  of  a  limb  naturally  occasions  the  parents 
the  greatest  anxiety.  In  the  adult,  a  paralytic  seizure  is  generally  the 
result  of  a  very  serious  disease  either  in  the  brain  or  spinal  cord,  and 
the  sign  of  the  commencement  of  a  series  of  morbid  processes,  which 
issue  sooner  or  later  in  the  destruction  of  the  patient's  life.  Non- 
professional persons  are  aware  of  this  fact,  and  suppose  that  the  same 
rule  holds  good  in  the  case  of  the  child  as  in  that  of  the  adult ;  but  you 
may  in  most  instances  quiet  their  fears  with  the  assurance  that  paralysis 
in  infancy  and  childhood  seldom  betokens  any  peril  to  life,  though  the 
affection  is  often  very  slow  in  disappearing,  and  sometimes  is  quite 
incurable. 

Paralysis  in  childhood  occasionally  dates  from  so  early  a  period  that 
there  seems  every  reason  for  believing  it  to  be  the  result  of  some  original 
defect  of  conformation.  In  such  cases  the  power  over  both  extremities 
on  one  side  is  greatly  impaired,  and  the  limbs  on  that  side  are  much 
smaller  and  less  well-nourished,  and  sometimes  the  defective  growth  and 
want  of  power  are  evident  on  the  whole  of  the  same  side  of  the  face  and 
body.  Some  years  ago,  I  saw  a  girl,  18  years  old,  in  whom  not  only 
were  the  left  extremities  much  shorter  and  smaller  than  the  right,  but 
the  left  half  of  the  face  and  body  was  so  likewise.  The  parents  of  the 
girl  stated  that  this  inequality  in  size  of  the  two  halves  of  the  body  had 
existed  from  earliest  infancy,  and  that  the  defective  power  over  her 
limbs  had  not  succeeded  to  a  fit,  nor  to  any  other  indication  of  acute 
cerebral  disease.  The  left  side  was  weak,  and  motion  imperfect,  but 
sensation  seemed  to  be  unimpaired.  The  patient  in  this  case  was  rather 
deficient  in  intellectual  endowments.  In  another  instance  the  body  was 
well  formed,  but  the  patient,  a  girl  of  eight  years  of  age,  had  had  from 
her  earliest  infancy  but  very  imperfect  use  of  her  right  side.  She  limped 
with  her  right  leg  as  she  walked,  always  treading  on  her  toes,  with  the 
heel  raised  considerably  above  the  ground,  and  turning  her  foot  inwards 
at  every  step.  She  had  but  very  incomplete  power  over  her  right  arm  ; 
the  fingers  of  that  hand  were  constantly  flexed  and  drawn  into  the  palm; 
and  though  by  a  great  effort  she  could  extend  them,  yet  the  moment 
her  attention  was  withdrawn  they  returned  to  their  former  flexed  position. 
Sensation  was  as  perfect  in  the  right  limbs  as  in  the  left,  but  their 
wasted  condition  and  smaller  size,  as  compared  with  the  left  extremities, 
shewed  that  their  nutrition  had  been  but  very  imperfectly  carried  on. 

It  is  almost  needless  to  observe,  that  in  cases  such  as  these  there  is 
no  room  for  treatment  other  than  the  employment  of  such  mechanical 
means  as  may  be  calculated  to  relieve  inconvenience  or  to  diminish 
deformity.  * 

Real  congenital  paralysis,  however,  is  a  much  less  frequent  accident 
than  the  occurrence  of  partial  or  complete  loss  of  power  over  certain 


PARALYSIS   UNCONNECTED   WITH   SERIOUS   CEREBRAL  DISEASE —      141 

limbs  or  muscles  at  a  subsequent  period.  In  many  instances  its  com- 
mencement can  be  traced  to  some  attack,  though  often  a  very  brief  one, 
of  cerebral  disturbance,  which  showed  itself  perhaps  by  nothing  more 
than  a  single  convulsive  seizure,  or  by  an  unusual  heaviness  of  the  head 
that  lasted  for  a  day  or  two,  and  then  subsided  of  its  own  accord.  In 
the  majority  of  cases,  indeed,  the  cerebral  disturbance  that  precedes 
infantile  paralysis  is  neither  severe  nor  long-continued  ;  and  only  two 
instances  have  come  under  my  notice  in  which  there  seemed  to  be  reason 
for  supposing  that  it  was  associated  with  abiding  mischief  in  the  brain. 
It  is  therefore  of  importance  to  examine  an  infant  carefully,  even  after 
a  very  mild  convulsive  seizure,  in  order  to  make  sure  that  it  moves  its 
limbs  as  freely  as  before,  or  that,  if  its  power  over  them  be  impaired, 
appropriate  treatment  may  be  at  once  adopted. 

Paralysis  sometimes  comes  on  independently  of  any  evident  cerebral 
disturbance,  seeming  to  be  induced  by  the  irritation  of  dentition,  or 
supervening  on  the  long  continuance  of  a  constipated  state  of  the  bowels, 
or  appearing  in  connection  with  all  the  indications  of  general  debility,  or 
succeeding  to  a  short  feverish  seizure  which  came  on  suddenly  when  the 
child  was  in  bed  at  night,  and  left  it  with  one  limb  palsied  in  the  morning. 
The  local  action  of  cold  sometimes  produces  paralysis.  I  have  met 
with  one  or  two  instances,  in  which,  after  sitting  for  some  time  on  a  stone 
step,  a  child  has  lost  power  over  one  leg  ;  and  paralysis  of  the  portio 
dura  is  doubtless  in  some  cases  produced  by  cold  air,  though  I  do  not  at 
this  moment  recall  an  instance  of  this  having  been  the  case  in  children. 

The  duration  of  infantile  paralysis,  under  whatever  circumstances  it 
may  have  come  on,  is  extremely  variable.  In  some  instances  it  dis- 
appears during  the  employment  of  some  simple  remedy  directed  against 
the  symptoms  of  constitutional  disorder  with  which  it  was  accompanied, 
and  the  same  medicine  suffices  at  once  to  remove  the  child's  indisposition, 
and  to  cure  its  paralysis.  In  other  cases,  even  though  all  signs  of 
disordered  health  may  pass  away  with  the  same  rapidity,  the  child  may 
continue  for  weeks  or  months  with  the  power  over  one  side  of  its  body, 
or  one  half  of  its  face,  or  one  of  its  limbs,  greatly  impaired ;  or  this 
condition  may  persist  through  the  remainder  of  its  life. 

Cases  might  be  related  in  illustration  of  all  these  varieties  in  the  form 
of  infantile  paralysis,  in  its  onset  and  its  duration  ;  but  time  will  not 
allow  me  to  do  more  than  to  refer  you  to  this  Table  which  embodies  the 
most  important  points  in  the  history  of  twenty  cases  of  paralysis  in 
infants  or  children. — [See  pp.  142-3.] 

If  we  leave  out  of  the  question  the  two  cases  in  which  the  paralysis 
seemed  to  be  congenital,  we  shall  find  that,  in  thirteen  out  of  eighteen 
instances,  it  occurred  between  eight  months  and  three  years  of  age, — 
or,  in  other  words,  during  that  time  when  the  process  of  dentition  is 
going  on  most  actively.  In  many  of  these  cases,  indeed,  it  was  not 
preceded  by  any  of  the  local  signs  of  difficult  dentition ;  but  still  it  is 
quite  apparent  that  the  changes  that  are  going  on  in  the  constitution 
during  that  important  period  of  development  powerfully  predispose  to  the 
affection.  There  were  but  two  instances  in  which  there  seemed  to  be 
any  reason  for  regarding  the  paralysis  as  connected  with  permanent 
disease  of  the  brain ;  and  in  eight  out  of  the  eighteen  cases  no  indica- 


142 


HISTORY   OF   TWENTY   CASES   OP 


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144  MOST  COMMON   DURING  DENTITION. 

tion  of  cerebral  disturbance  occurred  before  the  paralysis,  or  came  on 
afterwards. 

In  the  two  cases  in  which  the  disorder  was  congenital,  both  extrem- 
ities of  one  side  were  palsied,  and  in  one  of  them  the  power  over  the  same 
side  of  the  face  was  likewise  impaired.  In  seven  of  the  other  eighteen 
cases  the  leg  only  was  affected,  and  in  two  of  these  the  power  over  both 
legs  was  lost ;  in  fiVe  both  the  leg  and  arm  were  palsied,  while  in  six 
instances  facial  paralysis  existed.  In  four  of  these  six  cases  the  paralysis 
of  the  portio  dura  was  not  associated  with  impaired  power  over  any  of 
the  limbs  ;  once  it  was  combined  with  palsy  of  the  leg,  and  once  with 
a  general  impairment  of  the  power  of  walking. 

One  point  which  it  behooves  us  to  bear  in  mind  in  connection  with 
these  cases  is,  that  though  cerebral  symptoms,  or  any  other  form  of  dis- 
turbance of  the  general  health  that  may  have  preceded  the  paralysis, 
usually  subside  in  a  short  time,  there  is  still  very  great  danger  of  the 
paralysis  continuing  in  such  a  degree  as  to  cause  much  disfigurement,  or 
as  to  interfere  greatly  with  the  usefulness  of  the  limb.  In  only  six  of 
the  eighteen  cases  did  a  cure  of  the  palsy  take  place  :  in  two  of  these 
cases  the  portio  dura  alone  was  affected;  in  two  others  the  paralysis  of 
both  leg  and  arm  was  incomplete,  and  was  associated  with  a  state  of 
general  debility;  and  in  one  the  loss  of  power  over  one  leg  had  come  on 
after  the  child  had  been  sitting  for  some  hours  on  a  stone  door-step.  In 
four  of  these  cases  treatment  was  commenced  within  two  or  three  days 
after  the  occurrence  of  the  paralysis,  and  continued  uninterruptedly  until 
the  patient's  recovery.  In  one  the  treatment  was  begun  after  the  lapse 
of  nearly  three  weeks ;  and  in  another,  though  begun  immediately,  it 
was  discontinued  for  some  weeks.  In  four  instances  partial  improve- 
ment took  place,  and  there  seems  reason  for  anticipating  that  in  one  (No. 
20)  this  improvement  will  go  on  to  complete  recovery.  In  Nos.  7  and 
17  the  improvement  was  but  slight ;  in  both  these  cases,  however,  there 
was  more  serious  cerebral  disease  than  in  any  others.  The  treatment 
of  No.  14  was  continued  only  for  a  week;  and  though  the  child  gradu- 
ally recovered  power  over  the  arm,  yet  the  leg  remained  quite  useless. 
In  the  other  three  cases  treatment  was  begun  within  a  few  days,  and 
was  continued  without  interruption.  In  the  eight  cases  in  which  no  treat- 
ment was  adopted,,  or  not  till  after  the  lapse  of  a  period  of  six  months, 
no  improvement  took  place  in  the  patient's  condition.  It  would  be  dif- 
ficult to  find  an  argument  to  enforce  the  necessity  for  the  early  adoption 
of  appropriate  treatment  more  cogent  than  is  furnished  by  these  facts. 
The  evil  results  of  neglecting  it,  too,  are  in  some  respects  more 
serious  in  the  child  than  in  the  adult,  since  the  disfigurement  that  is 
produced  by  paralysis  is  greater  in  childhood  than  in  adult  age.  The 
muscles  of  a  paralysed  limb  are  almost  always  observed  to  be  wasted ; 
but  in  childhood  the  growth  of  the  part  becomes  arrested,  and  in  the 
course  of  a  year  or  two  it  will  be  half  or  three-quarters  of  an  inch 
shorter  than  the  corresponding  member  on  the  opposite  side.  On  two 
occasions  I  have  seen  the  arm  completely  dislocated,  owing  to  its  long 
standing  paralysis,  the  ligaments  about  the  shoulder-joint  having  become 
so  relaxed  that  the  head  of  the  humerus  hung  quite  out  of  the  glenoid 
cavity ;  and,  on  measuring  the  distance  from  the  acromion  to  the  tip  of 


INFANTILE  PARALYSIS — RECOVERY   UNCERTAIN.  145 

the  finger  in  one  of  these  cases,  I  found  that  an  apparent  elongation  of 
the  paralysed  limb,  to  the  extent  of  three-quarters  of  an  inch,  had  thus 
been  produced. 

The  diagnosis  of  these  cases  is  not  likely  to  be  attended  with  any 
difficulty  ;  for  the  history  of  the  case,  and  the  painlessness  of  the  affect- 
ed limb,  will  at  once  show  that  the  loss  of  power  over  it  is  not  the  result 
of  any  injury.  Now  and  then,  however,  sensation  in  the  affected  limb 
appears  to  be  exalted, — a  circumstance  which,  when  the  leg  is  the  seat 
of  the  affection,  and  the  paralysis  is  incomplete,  may  lead  to  the  appre- 
hension of  hip-joint  disease.  In  such  a  case  the  child  bears  all  its 
weight  on  the  healthy  limb,  turns  the  foot  of  the  affected  side  inwards 
when  walking,  and  stands  with  the  toes  of  that  foot  resting  on  the  dor- 
sum of  the  foot  of  the  healthy  side.  Still  it  will  usually  be  found  that 
the  exaggerated  sensibility  of  the  paralysed  limb  varies  greatly  at  dif- 
ferent times,  while  that  extreme  increase  of  suffering  produced  in  cases 
of  hip-joint  disease,  on  striking  the  head  of  the  femur  against  the  ace- 
tabulum by  a  blow  upon  the  heel,  and  the  fixed  pain  in  the  knee  of  the 
affected  side,  so  characteristic  of  disease  of  the  hip-joint,  are  absent ; 
and  these  points  of  difference  will  usually  enable  you  to  distinguish  be- 
tween the  two  affections. 

Another  important  question  is,  how  we  may  distinguish  between  forms 
of  paralysis,  such  as  I  am  here  speaking  of,  and  those  more  serious  cases 
in  which  the  palsy  is  a  sign  of  organic  disease  in  the  brain.  In  many 
cases  the  history  of  the  patient  will  of  itself  be  sufficient  to  guard  you 
from  error ;  for  if  paralysis  occur  suddenly,  affecting  both  limbs  on  one 
side,  and  be  neither  preceded  by  nor  attended  with  any  cerebral  symptom, 
it  is  almost  certain  that  it.does  not  depend  on  serious  organic  disease  of 
the  brain.  Our  decision  will  be  more  difficult  if  the  loss  of  power  have 
been  gradual,  and  especially  if  only  one  limb  be  affected ;  but  if  the  brain 
be  diseased,  you  will  rarely  find  a  mere  weakening  of  the  motor  power  ; 
for  connected  with  it  there  will  usually  be  occasional  involuntary  tremor 
or  nervous  twitching  of  the  limb,  or  contraction  of  the  fingers  or  toes. 
When  the  paralysis  succeeds  to  convulsions,  the  case  will  be  still  more 
obscure.  In  most  cases  of  simple  paralysis,  however,  the  palsy  comes 
on  after  a  single  fit ;  while,  if  it  depend  on  some  local  mischief  in  the 
brain,  it  is  generally  preceded  by  several  convulsive  seizures,  during 
each  of  which  the  limb  that  afterwards  becomes  palsied  is  in  a  state 
of  peculiar  movement,  or  is  sometimes  the  only  part  where  convulsive 
movements  occur. 

Each  one  of  these  cases  must  be  treated  according  to  the  peculiar 
features  that  it  may  present.  Purgatives  and  tonics  are  the  remedies 
which  I  have  most  frequently  employed ;  for  the  bowels  are  usually 
constipated,  and  the  child  is  often  debilitated.  The  gentler  aperients 
are  more  suitable  in  these  cases  than  drastic  purgatives  ;  and  you  will 
gain  more  good  from  the  preparations  of  iron  than  from  other  tonics. — 
I  have  sometimes  used  stimulating  embrocations  to  the  spine  and  to  the 
paralysed  limb,  though  rather  for  the  sake  of  satisfying  the  relations, 
than  with  the  hope  of  doing  any  very  great  good  to  the  patient.  Elec- 
tricity applied  to  the  affected  limb,  in  the  form  of  weak  currents  from 
an  electro-magnetic  machine,  t^ice  in  the  day,  is  a  most  valuable  adjunct 

10 


146  INFANTILE   PARALYSIS — TREATMENT.      FACIAL  HEMIPLEGIA. 

to  other  treatment,  so  soon  as  any  symptoms  of  general  constitutional 
disturbance,  that  may  have  attended  the  onset  of  the  affection,  have 
been  removed.  Like  other  remedies  in  such  cases,  the  chances  of  doing 
good  by  its  employment  seem  to  depend  in  no  small  measure  on  its 
being  resorted  to  early :  while  it  must  further  be  confessed,  that  it  is 
rather  uncertain  in  its  action ;  for  while  sometimes  very  marked 
improvement  has  followed  its  use,  in  other  cases,  for  which  it  seemed 
equally  suitable,  its  employment  has  occasioned  much  pain,  without  being 
followed  by  any  increase  of  power  over  the  limbs.  In  Case  XX.,  the 
application  of  blisters  to  the  spine,  was  succeeded  by  marked  im- 
provement, though,  as  I  was  giving  at  the  same  time  the  spirituous 
extract  of  the  nux  vomica,  I  do  not  know  how  much  of  the  improvement 
to  attribute  to  the  external,  and  how  much  to  the  internal  remedy. 

If  the  portio  dura  be  paralysed,  you  must  adopt  the  same  general 
treatment,  but  must  bear  in  mind  the  possibility  of  the  nerve  having 
undergone  pressure  from  some  enlarged  gland ;  and  if  you  find  reason 
to  believe  this  to  be  the  case,  you  may  apply  a  leech  in  the  situation 
where  the  nerve  passes  out  of  the  skull, — a  proceeding  which  I  once 
adopted  with  advantage. 

Lastly  I  will  mention  that  infants  are  sometimes  born  with  facial 
hemiplegia,  as  the  result  of  injury  to  the  nerve  from  application  of  the 
midwifery  forceps,  or,  as  has  in  one  or  two  cases  been  observed,  from 
injury  received  during  the  passage  of  the  head  through  the  pelvis  without 
any  instruments  having  been  employed.  Such  occurrences  are  rare,  but 
it  is  well  that  you  should  be  aware  of  the  possibility  of  their  being  met 
with,  independent  of  any  injury  to  the  brain.  The  paralysis  in  these 
cases  generally  disappears  in  the  course  of  a  few  days  or  weeks.1  In 
the  only  case  of  the  kind  which  has  come  under  my  own  observation, 
the  distortion  of  the  face,  though  very  great  at  birth, — one  eye  being 
wide  open,  and  the  corresponding  side  of  the  face  powerless,  so  that  the 
child  was  unable  to  suck, — had  already  greatly  diminished  within  forty- 
eight  hours,  and  had  quite  disappeared  within  a  week. 


LECTUEE  XIII. 

Diseases  op  the  Respiratory  Organs,  their  frequency  and  fatality. — Peculiarities  of 
the  respiratory  function  in  early  life — causes  of  the  rapid  pulse  and  quick  breathing 
in  infancy — feebleness  of  inspiratory  power,  and  consequent  tendency  to  collapse  of 
the  lung. 

Imperfect  Expansion  of  the  Lungs — sometimes  congenital. — Appearance  of  the  lung 
— influence  of  inflation  upon  it — its  causes  and  symptoms. — Case  of  its  fatal  termina- 
tion— case  of  recovery  from  it. — Diagnosis  from  congenital  phthisis. — Treatment. 

We  now  come  to  the  examination  of  the  diseases  of  those  two  grand 
systems  of  the  organism  by  which  the  blood  is  kept  in  motion,  the 

1  Kennedy's  Observations  on  Apoplexy,  Paralysis,  &c.  of  New-born  Infants, — in 
Dublin  Journ.  of  Med.  Science,  1836  ;  and  Landouzy  sur  I'He'miple'gie  Faciale  chez  les 
enfans  nouveau-n6s.     8vo.  Paris,  1839. 


PECULIARITIES   OF   THE   RESPIRATORY   FUNCTIONS  IN   EARLY  LIFE.      147 

requisite  changes  in  it  are  effected,  and  the  animal  heat  is  maintained. 
Your  attention  was  lately  called  to  the  fatality  of  the  diseases  of  the 
nervous  system  in  early  life  as  one  grand  reason  for  their  attentive 
study ;  but  this  argument  is  still  more  cogent  if  applied  to  the  maladies 
of  the  organs  of  respiration  and  circulation,  since  they  destroy  a  far 
greater  number  of  children,  and  occasion  a  mortality  almost  equal  to 
that  produced  by  diseases  of  the  nervous  and  digestive  systems  together. 
It  appears,  indeed,  from  our  tables  of  mortality,  that  very  nearly  a 
third  of  all  deaths  under  five  years  of  age  are  due  to  the  diseases  of  the 
respiratory  organs  ;  while  not  above  one  child  in  four  dies  under  that 
age  from  diseases  of  the  nervous  system,  and  not  above  one  in  seven 
from  those  of  the  digestive  system.1 

While  the  study  of  these  diseases  is  of  paramount  importance,  we 
meet  with  inducements  to  their  investigation  which  in  a  great  measure 
failed  us  in  the  case  of  diseases  of  the  nervous  system.  Peculiar  diffi- 
culties then  attended  us,  and  the  truth  was  veiled  in  so  much  obscurity, 
that  we  often  saw  it  but  indistinctly — sometimes,  perhaps,  altogether 
failed  to  perceive  it.  The  same  means,  however,  as  have  enabled  us  to 
bring  medical  knowledge,  with  reference  to  the  diseases  of  the  chest  in 
the  adult,  almost  to  the  state  of  one  of  the  exact  sciences,  still  stand  us 
in  stead  here ;  and  care  and  patience  will  enable  us  to  discover  the 
condition  of  the  lungs  with  nearly  as  much  certainty  in  an  infant  as  in 
a  grown  person. 

Nor  is  the  greater  facility  of  their  diagnosis  the  only  circumstance 
that  lightens  their  study,  but  a  feeling  of  hopefulness  attends  their  in- 
vestigation /which  we  often  missed  in  the  subjects  that  have  lately 
engaged  our  attention.  They,  indeed,  furnish  us  with  interesting 
pathological  studies :  we  stood  around  the  sick  bed,  and  watched  nature's 
struggles  with  disease  that  was  irremediable,  and  we  traced  its  effects 
afterwards  as  we  examined  the  dead  body ;  but  the  diagnosis  of  the 
affection  was  in  many  instances  but  the  sentence  of  the  patient's  death ; 
and  we  often  felt  that,  as  practical  physicians,  there  was  but  little  for 
us  to  do.  We  shall,  it  is  true,  meet  with  some  such  affections  in  our  study 
of  diseases  of  the  chest,  but  happily  they  are  few  in  comparison  with 
those  which,  in  addition  to  much  that  would  interest  the  mere  pathol- 
ogist, present  still  more  that  will  give  ample  scope  for  all  the  skill  of 
the  practical  physician. 


1  Table  showing  the  proportion  per  cent,  of  deaths  from  different  causes  in  childhood, 
in  the  metropolis,  as  compared  with  subsequent  life.  [Deduced  from  the  5th  and  8th 
Reports  of  the  Registrar-General,  for  1842  and  1845.] 


From  Diseases    of    the    Nervous 
System 

Ditto,  ditto,  Respiratory  System.. 
Ditto,  ditto,  Digestive  System 


Under    Between 
1  year.    1  and  3. 


30.5      18.5 


I 

26.9 
17.5' 


39.5 
12.8 


At  all 

Between 
3  and  5. 

Under 
5. 

5  to  10. 

10  to  15. 

Ages 

above 

15. 

17.6 

24.3 

15.1 

10.6 

10.4 

33. 

32.8 

29.5 

30.7 

38.0 

5.5 

14.1 

6.5 

8.8 

7.7 

148        CAUSES   OF   RAPID   PULSE   AND   QUICK   BREATHING   IN   INFANCY. 

At  first  sight,  it  may  seem  to  you  that  there  can  be  little  in  the 
organs  of  respiration  and  circulation  in  early  life  different  from  their 
condition  in  riper  years.  And  it  is  true  that  the  part  they  play  is  as 
important  at  the  first  hour  of  existence  as  in  the  most  advanced  old  age, 
and  that  their  structure  and  functions  undergo  no  such  changes  as  we 
have  noticed  taking  place  in  the  brain  during  infancy  and  childhood ; 
but  nevertheless,  they  present  some  important  peculiarities  in  the  young, 
with  which  you  must  be  acquainted  before  you  can  hope  to  treat  their 
diseases  with  success. 

The  condition  of  infancy  is  one  of  unceasing  development ;  all  the 
organs  of  vegetative  life  have,  so  to  speak,  double  work  to  do, — not 
merely  to  supply  the  daily  waste,  and  to  remove  effete  and  useless 
matter,  but  to  build  up  that  wondrous  edifice,  the  human  body.  It  is 
probably  in  great  measure  on  this  account  that  the  blood  in  infancy  and 
childhood  runs  its  course  more  rapidly,  and  that  the  lungs  vivify  it  more 
frequently  than  in  adult  age.  We  shall  probably  not  be  far  wrong  if 
we  estimate  the  average  frequency  of  the  pulse  in  the  grown  person, 
when  making  no  exertion,  at  75,  and  of  the  respirations  at  12  in  the 
minute.1  In  infants  not  above  a  week  old,  the  average  frequency  of 
the  respiration  is  39,  and  of  the  pulse  102  ;  but  the  former  may  rise  to 
84,  and  the  latter  to  140,  as  the  result  of  some  transient  excitement  or 
disturbance,  and  wholly  independent  of  disease.  Until  the  sixth  year 
the  average  frequency  of  the  pulse  continues  at  102  ;  and  though  that 
of  the  respiration  diminishes,  yet  it  does  not  fall  below  30.  The  varia- 
tions between  their  maximum  and  minimum  frequency  are  now,  however, 
circumscribed  within  limits  which  grow  narrower  as  the  child  approaches 
manhood.2 

Although  the  rapid  pulse  and  quick  breathing  of  early  life  are  pro- 
bably in  great  measure  due  to  the  activity  of  the  vital  processes,  yet 
the  wide  variations  in  their  frequency  induced  by  very  slight  accidents 
lead  to  the  suspicion  that  this  is  not  their  only  cause,  but  that  both 
phenomena  are  to  a  certain  extent  indications  of  the  infant's  weakness. 
This  suspicion  is  still  further  strengthened  by  our  knowledge  of  the 
fact,  that  the  quantity  of  carbonic  acid  exhaled  at  each  expiration 
diminishes  in  proportion  as  the  expirations  are  more  frequent  ;3  so 
that  it  is  plain  that  the  rapidity  of  the  respiratory  movements  is  not  of 
itself  a  measure  of  the  activity  of  the  respiratory  process.  But  still 
stronger  proof  of  this  fact  may  be  adduced.  Animal  heat  is  generated 
almost  entirely  by  respiration.  If,  therefore,  the  activity  of  the  vital 
processes  were  in  proportion  to  the  rapidity  of  the  breathing,  the  new- 
born infant  should  be  warmer  than  the  child,  and  the  child  than  the 
youth.  But  this  is  not  so,  for  M.  Roger  has  found,  as  the  result  of 
many  most  elaborate  investigations,  that  the  temperature  of  the  child 
at  six  years  of  age  exceeds  that  of  the  infant  of  a  week  old  by  more 

1  This  result  is  afforded  by  the  numerous  and  careful  observations  of  Professor 
Vierordt:  see  his  article  Respiration,  in  Wagner's  Handworterbuch  der  Physiologie, 
Part  12,  8vo.  Brunswick,  1845,  p.  874. 

The  chief  authority  for  the  statement  in  the  text  is  the  valuable  essay  of  M  Roger, 
De  la  Temperature  chez  les  Enfants,  8vo.  Paris,  1844. 

a  See  Vierordt's  experiments  on  this  subject,  loc.  cit   p.  887. 


FEEBLENESS   OF   THE  INSPIRATORY  POWER.  149 

than  half  a  degree  of  Fahrenheit,  although  the  respiration  is  nearly  a 
fourth  less  frequent.1 

There  seems,  then,  good  reason  for  believing  that  the  rapid  breathing 
of  the  child  is  to  some  extent  the  result  of  its  more  delicate  frame, 
rendering  it  unable,  at  a  single  effort,  to  inspire  as  deeply  as  the  more 
robust  adult,  so  that  it  is  compelled,  by  the  frequent  repetition  of  its 
efforts,  to  make  up  for  their  comparative  feebleness.  Quite  in  keeping 
with  this  is  the  small  power  of  resisting  cold,  or  of  maintaining  an 
independent  temperature,  which  is  the  distinguishing  peculiarity  of 
early  life.  If  the  young  of  any  warm-blooded  animal  be  exposed  to  a 
low  temperature,  its  respiration  at  first  increases  in  frequency,  but  if 
not  soon  restored  to  a  warmer  atmosphere,  the  nervous  energy  that 
should  set  the  respiratory  apparatus  in  motion  becomes  still  more 
depressed ;  air  enters  the  lungs  imperfectly,  the  inspirations  grow  less 
frequent,  and  the  warmth  of  the  body  sinks  rapidly  down  to  that  of  the 
surrounding  medium.  Nor  is  this  all ;  but  it  often  happens,  if  a  young 
infant  has  been  thus  exposed  to  the  cold,  and  especially  if  this  has  been 
done  before  the  respiration  had  become  properly  established,  that  no 
subsequent  removal  to  a  warmer  atmosphere  will  suffice  to  raise  the 
temperature,  or  to  set  in  proper  activity  the  respiratory  process. 

But  not  merely  is  the  respiratory  apparatus  more  delicate  in  the 
child  than  in  the  adult,  for  so  are  all  the  organs  in  early  life,  but  it  is 
feebler,  as  compared  with  the  work  it  has  to  do,  with  the  difficulties  it 
has  to  overcome  :  and  this  constitutes  a  most  important  peculiarity  in 
the  physiology  of  respiration  in  early  life,  and  greatly  modifies  its 
pathology. 

The  interesting  researches  of  Mr.  Hutchinson3  have  shown  us  that 
in  the  case  of  the  adult  "the  resistance  to  the  ordinary  breathing  force, 
independently  of  the  elastic  power  of  the  lungs,  is  equal  to  lifting  more 
than  100  lbs.  at  every  ordinary  inspiration."  The  elasticity  of  the 
walls  of  the  chest  which  present  this  resistance,  is,  in  proportion  to  the 
size  of  the  thorax,  nearly  as  great  in  the  infant  as  in  the  adult ;  but 
how  much  smaller  is  the  muscular  power  by  which  this  resistance  is  to 
be  overcome  !  You  see  proof  of  it  in  the  ordinary  mode  o£  respiration 
of  a  young  infant,  which  presents  something  almost  of  difficulty.  The 
breathing  is  quick  and  short,  then  after  a  few  seconds  there  succeeds  a 
pause,  and  then  the  hurried  respiratory  movements  begin  again,  while 
the  slightest  disturbance,  or  the  most  trivial  excitement,  will  at  any 
time  raise  the  frequency  of  the  inspirations  by  ten  or  twelve  in  the 
minute.  This  respiration,  too,  is  almost  entirely  abdominal ;  the  chest 
moves  but  little,  its  walls  are  but  little  expanded,  and  the  ear  detects 
in  the  respiratory  murmur  little  or  nothing  of  that  clear  loud  sound 
which  is  so  characteristic  of  a  subsequent  period  of  childhood,  and  with 
which  you  all  are  familiar  by  the  name  of  puerile  respiration.  This  pecu- 
liarity of  the  breathing  in  early  infancy,  to  which  M.  Trousseau  was,  I 


1  The  recent  researches  of  Dr.  v.  B'arensprung,  published  in  Miiller's  Archiv.  1851, 
p.  125,  do  not  confirm  the  above  statement,  but  they  are  too  few  in  number  to  invalidate 
it,  and  therefore  it  is  still  retained  in  the  text.     See  \  5  of  v.  Barensprung's  essay. 

2  On  the  Respiratory  Functions,  in  vol.  xxix.  of  the  Medico-Chirurgical  Transactions. 


150  IMPERFECT  EXPANSION  OF  THE  LUNGS. 

believe,  the  first  to  call  attention,  is  another  token  of  the  feebleness  of 
the  inspiratory  power.  As  the  child  grows  older,  and  its  strength 
increases,  and  its  muscular  system  becomes  more  developed,  the  chest 
expands  with  each  inspiration,  and  the  faint  respiratory  murmur  is  suc- 
ceeded by  the  loud  puerile  breathing  which  is  heard  as  the  air  enters 
into  the  smaller  air-cells. 

The  resistance  of  the  walls  of  the  chest,  however,  is  not  the  only 
obstacle  to  be  overcome,  at  each  inspiratory  effort,  but  the  lungs  them- 
selves are  .furnished  with  an  elastic  fibrous  investment,  processes  of 
which  dip  down  into  their  substance,  and  form  the  parietes  of  the  dif- 
ferent lobules.  If  you  blow  air  forcibly  into  the  lungs  after  their 
removal  from  the  body,  the  resiliency  of  their  tissue  will  expel  a  large 
proportion  of  the  air  the  moment  your  effort  at  inflation  is  suspended. 
This  elasticity  of  the  lungs,  then,  which  has  been  estimated  as  offering 
in  the  adult  male  an  obstacle  to  each  inspiration  equal  to  150  lbs.,  and 
in  the  female  equal  to  120  lbs.,  avoirdupois,  is  constantly  tending  to 
empty  them  of  air,  and  constantly  resisting  the  introduction  of  more.1 
The  want  of  breath,  however,  puts  the  respiratory  muscles  into  play ; 
the  man  takes  a  deep  inspiration,  and  by  this  effort  he  unconsciously 
overcomes  the  resistance  of  the  chest  and  the  elasticity  of  the  lungs. 
The  new-born  infant  feels  the  same  want,  and  makes  the  same  effort, 
but  its  muscular  power  is  small,  and  its  inspirations  are  often  so 
feeble  as  to  draw  the  air  in  some  parts  only  into  the  larger  bronchi, 
while  many  of  the  smaller  air-tubes  remain  undilated,  and  much  of  the 
lung  continues  in  its  foetal  state.  The  blood  being  thus  but  imperfectly 
aerated,  all  the  processes  of  nutrition  go  on  imperfectly ;  the  vital 
powers  languish,  the  inspiratory  efforts  become  more  and  more  feeble, 
the  temperature  sinks,  and  the  infant  dies.  But  not  only  may  this 
state  persist  as  the  result  of  imperfect  respiration  at  birth,  but  cold,  or 
the  want  of  sufficient  food,  or  any  other  cause  that  impairs  the  already 
feeble  muscular  power,  favours  its  supervention.  As  the  power  of  the 
inspiratory  muscles  is  impaired,  the  air  no  longer  penetrates  into  the 
lungs  so  far  as  it  once  did,  while  the  residual  air  is  gradually  driven 
out  of  the  pulmonary  cells  by  the  elasticity  of  the  lung,  and  portions 
once  permeable  to  air  become,  in  the  course  of  time,  altogether  useless. 
Or,  an  increase  of  the  ordinary  resistance  to  the  entrance  of  the  air 
will  have  the  same  effect ;  and  if  the  pouring  out  of  mucus  into  the 
bronchial  tubes  should  much  obstruct  them,  large  portions  of  lung  will 
by  degrees  become  emptied  and  collapse,  the  dyspnoea  will  grow  urgent, 
and  the  child  will  die  from  symptoms  such  as,  in  the  adult,  result  only 
from  most  serious  structural  disease. 

The  possibility  of  a  large  portion  of  the  respiratory  apparatus 
remaining  useless  from  the  birth,  or  becoming  so  afterwards  without  any 
serious  disease  of  these  organs,  is  a  most  important  element  in  the 

1  The  investigations  of  Professor  Donders,  and  of  Mr.  Hutchinson,  into  the  amount  of 
this  elasticity  of  the  lungs,  though  carried  on  independently,  conduct  to  very  similar 
results  :  the  former  estimating  it  as  equal  to  ^ix.  gx.  avoirdupois  per  square  inch  as  a 
maximum :  the  latter  estimating  it  on  the  average  at  Ibss.  per  square  inch.  See  the 
researches  of  Prof.  Donders,  in  the  Nederlandsche  Lancet,  Dec.  1849  ;  and  Schmidt's 
Jahrb.  Dec.  1850 ;  and  article  Thorax,  by  Mr.  Hutchinson,  in  Cyclopaedia  of  Anatomy 
and  Physiology,  .vol.  xiv.,  p.  1058. 


IMPERFECT  EXPANSION   OF   THE  LUNGS.  151 

pathology  of  infancy  and  early  childhood.  It  warns  us  to  be  on  our 
guard  during  the  course  of  various  maladies,  against  a  danger  which,  in 
more  advanced  life,  we  have  not  to  apprehend ;  while,  at  the  same  time, 
it  teaches  us  that  the  dyspnoea,  the  hurried  breathing,  and  many  other 
symptoms  which,  in  the  adult,  would  call  for  most  active  treatment,  may 
result,  in  infancy,  from  simple  weakness,  and  require  stimulating  rather 
than  the  depletory  measures. 

Before  we  proceed  to  study  the  diseases  of  the  respiratory  organs  in 
infancy  and  childhood,  we  must  make  ourselves  thoroughly  acquainted 
with  this  state  of  imperfect  expansion  of  the  lungs.  It  presents  itself 
to  us  under  two  different  circumstances. 

1st.  As  a  congenital  condition :  a  more  or  less  considerable  portion 
of  the  lung  never  having  become  penetrated  by  air,  but  having  remained 
in  its  foetal  state. 

2d.  As  an  acquired  condition  :  portions  of  the  lung  which  once 
were  freely  traversed  by  air  ceasing  to  admit  it ;  and  this  not  from 
alteration  of  structure,  but  from  a  simple  collapse  of  the  pulmonary 
tissue. 

It  is  now  nineteen  years  since  Dr.  Edward  Jorg  gave  the  first  clear 
description  of  the  former  of  these  two  conditions,  to  which  he  applied 
the  rather  cramp  name  of  atelektasis,  from  a**^,  imperfect,  and 
txtaats,  expansion.1  We  will  first  study  this,  which  is  the  simpler  form 
of  the  affection,  and  the  examination  of  which  will  give  us  a  clue  to  the 
understanding  of  the  second  form. 

If  you  examine  the  body  of  a  new-born  infant,  or  of  one  that  has 
survived  its  birth  but  a  few  days,  you  will  sometimes  find  patches  of 
the  lung  of  a  dark  red  colour,  and  depressed  below  the  surrounding 
tissue,  thus  giving  to  the  surface  of  the  organ  an  uneven  appearance. 
These  darker  portions,  which  exactly  resemble  foetal  lung,  are  solid  to 
the  touch,  do  not  crepitate  at  all  under  the  finger,  and  sink  immediately 
if  thrown  into  water,  while  no  minute  air-bubbles  are  intermingled 
with  the  small  quantity  of  reddish  serum  which  pressure  causes  to  exude 
from  their  divided  substance.  They  are  not  friable  nor  as  easily  torn, 
their  cut  surface  is  perfectly  smooth,  closely  resembling  a  piece  of 
muscle,  and,  if  examined  under  a  lens,  the  pale  collapsed  air-tubes  are 
seen  intersecting  their  substance,  and  scarcely  distinguishable  from  the 
small  vessels,  which  are  almost  devoid  of  blood. 

If  air  be  blown  into  a  lung  some  lobules  of  which  have  this  appear- 
ance, it  will  permeate  the  collapsed  air-tubes  ;  the  pulmonary  vesicles 
will  by  degrees  become  distended,  and  the,  solid  lobules  will  rise  to  a 
level  with  the  rest  of  the  lung,  will  acquire  the  same  colour  and  con- 
sistence, and,  like  other  parts  of  the  organ,  will  float  in  water.  A 
single  inflation,  however,  is  by  no  means  sufficient  to  render  this  change 
permanent,  but  the  moment  the  tube  is  withdrawn  the  air  will  escape, 
and  the  lobules  recently  distended  will  again  collapse,  and  sink  below 
the  rest  of  the  lung ;  and  their  colour,  too,  will  become  dark,  though 
less  so  than  before.     Even  if  after  you  have  distended  the  lung  to  the 

1  In  his  dissertation  De  pulmonum  vitio  organico,  fee.,  Leips.  1832  ;  and  afterwards 
more  fully  in  his  work  Die  Fotuslunge  in  gebornen  Kinde,  8vo.  Grimma,  1835. 


152  EFFECTS   OF  INFLATION. 

utmost,  you  then  pass  a  ligature  round  the  bronchi,  and  allow  the  lung 
to  dry,  a  difference  will  still  in  general  be  very  perceptible  between  the 
size  of  the  air-vesicles  which  had  been  inflated  by  your  efforts,  and  of 
those  which  had  been  distended  during  life  by  the  natural  process  of 
respiration. 

The  force  required  thus  to  distend  the  collapsed  portions  of  the  lung 
is  very  variable :  sometimes  it  requires  all  the  force  you  can  possibly 
exert,  and  continued  for  some  minutes.  If  the  child  have  survived  for 
several  weeks,  the  air  will  penetrate  only  very  imperfectly  into  the 
collapsed  lobules,  while  in  some  parts  the  resistance  will  be  greater 
than  it  can  overcome,  and  the  most  forcible  inflation  will  be  followed 
by  no  effect.  The  situations  in  which  this  condition  is  most  frequently 
met  with,  are  the  languette  and  lower  edge  of  the  upper  lobes,  the 
middle  lobe  of  the  right  lung,  and  the  posterior  part  and  lower  edge  of 
the  lower  lobes;  and  inflation  restores  these  parts  to  a  natural  condition 
much  less  easily  than  it  does  any  patches  of  the  same  kind  in  other 
situations.  Whether  the  impermeability  of  some  collapsed  lobules  is 
owing  to  adhesions  having  taken  place  between  the  opposite  surfaces  of 
the  minuter  bronchi,  as  has  been  suggested,  I  cannot  pretend  to  say, 
but  the  supposition  is  plausible,  and  microscopical  researches,  according 
to  which  the  bronchi  of  a  portion  of  collapsed  lung  lose  their  lining  of 
tesselated  epithelium,  lend  it  a  still  further  degree  of  probability.1 

It  is  usual  to  find,  in  connection  with  this  state  of  the  parenchyma  of 
the  lungs,  that  the  pulmonary  vessels  contain  less  blood  than  usual, 
that  the  foramen  ovale  is  unusually  open,  and  the  ductus  arteriosus  but 
very  imperfectly  closed.  If  the  child  have  survived  its  birth  but  a 
short  time,  the  brain  is  frequently  found  congested  ;  but  otherwise  there 
is  often  nothing  observable  more  than  anaemia  of  all  the  organs,  together 
with  a  general  state  of  atrophy.  Sometimes  bronchitis  attacks  a  lung 
thus  affected,  and,  besides  the  presence  of  mucus  in  the  air-passages, 
there  is  then  very  often  a  state  of  congestion  of  the  lungs,  which 
renders  the  contrast  between  the  collapsed  and  the  healthy  lobules  less 
striking. 

The  causes  of  this  condition  are  not  clearly  made  out.  Dr.  Jorg  has 
attributed  great  importance  to  precipitate  labour  as  a  frequent  cause  of 
its  occurrence,  and  has  suggested  a  somewhat  fanciful  theory  to  explain 
its  mode  of  production.  He  conceives  that  one  grand  use  of  the 
uterine  contractions  is  gradually  to  enfeeble  the  circulation  through  the 
placenta,  and  thus  to  induce  in  the  foetus  that  besoin  de  respirer  which 
shall  excite  the  complete  establishment  of  respiration  immediately  on 
its  birth.  If,  however,  by  the  very  rapid  course  of  labour,  the  child 
should  be  born  while  the  foetal  circulation  is  still  going  on  with  unim- 
paired vigour,  the  want  of  air  will  not  be  experienced  by  the  child,  and 
its  attempts  to  breathe  will  be  feeble  and  imperfect.  It  is  probably 
better,  instead  of  indulging  in  speculations  of  this  sort,  to  content  our- 
selves with  the  simple  statement  that  when,  from  any  cause  whatever, 
the  establishment  of  respiration  at  all  has  been  attended  with  difficulty, 

1  See  a  paper  on  this  subject  by  Trof.  Kostlin,  in  Schmidt's  Jahrbucher,  1850,  No.  1, 
p.  28. 


CAUSES  OF  IMPERFECT  EXPANSION   OF   THE   LUNGS —  153 

there  is  a  very  great  probability  that  its  establishment  will  never  be 
complete,  but  that  some  lobules  only  will  receive  the  air,  while  it  will 
not  penetrate  into  other  parts  of  the  lung.  The  probability  of  this 
occurring,  too,  will  be  still  greater  if  the  children  be  'weakly,  or  ill- 
nourished  when  born,  or  if  they  be  exposed  soon  after  birth  to  cold  or 
other  unfavourable  hygienic  influences,  such  as  are  calculated  to 
interfere  with  the  due  performance  of  respiration. 

Cases  in  which  this  condition  of  the  lungs  exists  usually  present  the 
history  of  the  child  having  been  apparently  still-born ;  and,  though 
resuscitated  after  a  time,  yet  still  continuing  unable  to  utter  a  strong 
and  loud  cry  like  that  of  other  children.  Even  after  breathing  has 
gone  on  for  some  time,  such  children  usually  appear  feeble  ;  and  though 
they  may  have  attained  the  full  term  of  foetal  life,  yet  they  can 
scarcely  suck,  although  they  often  make  the  effort.  An  infant  thus 
affected  sleeps  even  more  than  new-born  infants  usually  do ;  its  voice  is 
very  feeble,  and  rather  a  whimper  than  a  cry ;  and  the  chest  is  seen  to 
be  very  little,  if  at  all,  dilated  by  the  respiratory  movements.  The 
temperature  falls,  the  skin  becomes  pale,  and  the  lips  grow  livid,  and 
often  slight  twitching  is  observed  in  the  course  of  a  few  hours  about  the 
muscles  of  the  face.  The  difficulty  in  sucking  increases,  the  voice 
grows  weaker  and  more  whimpering,  or  even  altogether  inaudible, 
while  respiration  is  attended  with  a  slight  rale,  or  an  occasional  cough ; 
and  the  convulsive  movements  return  more  frequently,  and  are  no 
longer  confined  to  the  face,  but  affect  also  the  muscles  of  the  extremities. 
Any  sudden  movement  suffices  to  bring  on  these  convulsive  seizures ; 
but  even  while  perfectly  still  the  child's  condition  is  not  uniform,  but 
it  will  suddenly  become  convulsed;  and  during  this  seizure  the 
respiration  will  be  extremely  difficult,  and  death  will  seem  momentarily 
impending.  In  a  few  minutes,  however,  all  this  disturbance  ceases, 
and  the  extreme  weakness  of  the  child,  its  inability  to  suck,  its  feeble 
voice,  and  its  frequent  and  imperfect  inspirations,  are  the  only 
abiding  indications  of  the  serious  disorder  from  which  it  suffers.  But 
the  other  symptoms  return  again  and  again,  till  at  length,  after  the 
lapse  of  a  few  days,  or  a  few  weeks,  the  infant  dies. 

But  I  will  relate  a  case  which  may  serve  to  impress  these  charac- 
teristics on  your  memory.  A  little  boy,  three  weeks  old,  was  brought 
to  me  at  the  Children's  Infirmary,  on  March  13, 1846.  He  was  puny, 
emaciated,  with  a  cold  surface  and  bloodless  conjunctiva.  His  face, 
which  was  wizened  like  that  of  an  old  man,  was  occasionally  distorted 
by  slight  convulsive  twitches  ;  and  these  fits,  as  the  mother  termed  them, 
were,  according  to  her  account,  sometimes  much  more  severe.  The 
abdomen  was  tympanitic,  and  it  alone  was  seen  to  move  during  respi- 
ration, there  being  hardly  any  lateral  expansion  of  the  chest.  The  ear 
applied  to  the  chest  heard  but  little  air  entering ;  and  the  cry  was  a 
stifled  whimper,  in  which  none  of  the  inspiratory  sound,  the  reprise  of 
French  writers,  was  distinguishable.  The  child  sucked  with  difficulty, 
and  had  wasted  ever  since  its  birth,  though  no  diarrhoea  existed,  but 
the  bowels,  on  the  contrary,  shewed  a  tendency  to  constipation. 

The  chest  was  rubbed  twice  a  day  with  a  stimulating  liniment,  and  a 
mixture  was  given  containing  some  ammonia  and  the  compound  tincture 


154  CASES  ILLUSTRATIVE  OP  ITS   SYMPTOMS. 

of  bark.  Under  this  treatment  the  child  appeared  to  improve;  it 
began  to  breathe  less  rapidly  and  in  a  less  laboured  manner,  and  its 
cry  became  louder.  The  parents,  however,  were  miserably  destitute, 
the  mother  in  an  ill  state  of  health,  so  that  her  milk  afforded  but  a 
very  imperfect  sustenance  for  the  child.  From  the  beginning  of  April 
he  grew  less  well,  and  began  to  have  occasional  attacks  of  general 
convulsions,  in  one  of  which  he  died  on  April  26,  1846. 

On  examining  the  body,  large  portions  of  both  lungs  presented  the 
appearance  which  I  have  described  as  characteristic  of  their  imperfect 
expansion ;  but  inflation  restored  them  to  a  crepitant  state.  Some 
patches,  however,  though  they  admitted  air  and  assumed  the  same 
colour  as  the  rest  of  the  lung,  yet  could  not  by  any  effort  be  dilated  so 
completely  as  to  rise  to  a  level  with  the  surrounding  tissue.  The 
foramen  ovale  was  open,  the  margin  of  the  valve  for  fully  half  its 
circumference  not  being  adherent,  although  the  valve  was  sufficiently 
large  for  its  closure.  The  ductus  arteriosus  also  was  quite  permeable, 
although  of  considerable  less  calibre  than  during  foetal  life. 

This  case  affords  a  very  good  specimen  of  one  way  in  which  the 
affection  leads  on  to  a  fatal  termination ;  but  sometimes,  and  probably 
in  those  instances  in  which  the  affected  portion  of  lung  is  not  so 
considerable,  a  less  formidable  train  of  symptoms  usher  in  the  fatal 
event.  Convulsive  twitchings,  such  as  I  have  before  mentioned,  do  not 
occur,  nor  are  periodic  exacerbations  of  the  symptoms  observed ;  but 
the  child  is  merely  feeble  and  its  breath  is  short,  and  it  has  an  occa- 
sional cough.  It  sucks,  though  with  difficulty,  but  it  loses  flesh,  the 
bowels  become  disordered,  and  medicine  is  unable  to  restrain  the 
diarrhoea.  The  unchecked  diarrhoea  increases  the  emaciation  and 
exhaustion  of  the  child  which  dies  at  length  worn  out  and  wasted 
to  a  skeleton. 

Sometimes,  too,  we  meet  with  cases  in  which  the  child  eventually 
recovers,  and  it  is  then  very  interesting  to  watch  the  gradual  diminu- 
tion in  the  frequency  and  violence  of  the  paroxysms  of  dyspnoea,  while 
the  respiration  grows  by  degrees  more  equable,  and  the  cry  louder,  the 
power  of  sucking  increases,  and  the  child  at  length  attains  to  perfect 
health. 

A  little  boy,  four  months  old,  was  placed  under  my  rcare  by  his 
mother,  who  informed  me  that  the  child  had  presented  in  some  unnat- 
ural position  during  labour,  so  that  manual  interference  was  required 
to  effect  her  delivery :  and  when  born  the  infant  appeared  dead,  and 
was  recovered  only  after  very  great  difficulty,  and  after  the  occurrence 
of  convulsions :  the  convulsions  had  since  returned  almost  every  day, — 
sometimes  indeed  they  occurred  several  times  in  the  same  day, — and 
always  came  on  with  greater  frequency  by  day  than  by  night.  The 
attempt  to  suck  often  induced  them,  as  did  also  any  rapid  movement 
about  the  room,  or  any  sudden  change  of  posture.  During  the  fits  the 
child  did  not  struggle  much,  but  he  always  turned  extremely  livid 
about  the  face  and  mouth.  No  fit  ever  lasted  longer  than  five 
minutes,  and  during  the  intervals  between  them  the  child  seemed 
pretty  well,  except  that  he  often  suffered  from  a  suffocating  cough. 

He  appeared  tolerably  well-grown  and  well-nourished,  and  the  tern- 


ILLUSTRATIVE  CASES.  155 

perature  of  the  surface  was  nearly  natural.  The  respiration,  however, 
was  very  hurried,  and  was  almost  entirely  abdominal,  the  chest  being 
hardly  at  all  expanded.  The  cry,  moreover,  was  feeble,  and  without 
reprise.  There  was  a  considerable  want  of  resonance  of  both  sides  of 
the  chest  posteriorly,  and  deficient  entrance  of  air  into  the  back  of 
both  lungs.  Both  the  dulness  and  the  scanty  admission  of  air  were 
more  obvious  in  the  left  than  in  the  right  infra-scapular  region,  and 
some  mucous  rale  was  heard  in  the  former  situation. 

The  child  was  placed  in  a  hot  bath,  and  an  emetic  was  given  it 
every  night ;  the  chest  both  in  front  and  back  was  rubbed  twice  a  day 
with  a  stimulating  liniment,  and  the  face  was  ordered  to  be  sprinkled 
with  cold  water  whenever  any  threatenings  of  the  fits  came  on. 

At  the  end  of  five  days  the  child  was  better,  and  the  cry  louder, 
though  without  any  distinct  reprise.  Small  doses  of  the  ferro-citrate 
of  quinine  were  now  combined  with  the  other  remedies,  while  the 
emetics  were  discontinued,  as  on  some  occasions  they  had  appeared  to 
excite  the  convulsions.  First  the  cry  grew  louder,  then  the  appearance 
improved,  and  the  manner  became  more  cheerful,  then  the  cough  was 
less  troublesome  and  the  breathing  less  habitually  wheezing,  and  at  the 
same  time  the  chest  began  to  expand  more,  and  the  marked  dulness  of 
its  lower  parts  gradually  diminished.  At  the  end  of  five  weeks  the 
child  was  discharged  with  increased  flesh  and  invigorated  strength, 
and  with  no  ailment  more  serious  than  a  slight  degree  of  wheezing 
respiration. 

The  history  of  this  patient  may  serve  to  show  us  that  even  very 
serious  symptoms  should  not  lead  us  to  despair  of  recovery,  while  it 
illustrates  the  importance  of  forming  an  accurate  diagnosis  between 
this  affection  and  congenital  phthisis,  (the  only  malady  with  which  it  is 
likely  to  be  confounded,)  lest  we  either  cherish  unfounded  expectations, 
or  discourage  hopes  that  might  reasonably  be  entertained. 

A  little  care  will  usually  suffice  to  enable  us  to  distinguish  between 
these  two  affections,  notwithstanding  some  general  points  of  resem- 
blance between  them.  The  symptoms  of  the  imperfect  inflation  of  the 
lungs  dated  from  the  infant's  birth  :  but  it  scarcely  ever  happens  that 
turberculous  disorganization  of  the  lung  is  so  extensive  in  the  new-born 
child  as  to  interfere  with  the  establishment  of  the  respiratory  function. 
But  not  only  do  not  the  symptoms  of  phthisis  appear  so  early,  but  they 
likewise  seldom  advance  so  rapidly  as  those  of  atelektasis.  Phthisis, 
too,  is  not  from  the  beginning  attended  with  the  same  debility,  nor  with 
difficulty  in  sucking,  while  it  is  associated  with  a  febrile  action  which  is 
quite  wanting  in  atelektasis.  The  head  symptoms  which  in  so  large  a 
number  of  cases  attend  the  imperfect  inflation  of  the  lungs,  are  absent 
in  phthisis ;  while,  lastly,  auscultation  would  furnish  some  clue  to  the 
real  nature  of  the  case  :  in  the  one  instance  there  would,  in  general, 
be  simply  a  deficiency  of  air ;  in  the  other,  respiration,  accompanied 
with  rales,  and  often  with  bronchial  breathing. 

The  treatment  required  by  this  affection  need  not  detain  us  long. 
The  importance  <of  maintaining  an  equable  temperature  around  every 
child  in  whom  respiration  is  not  duly  performed,  cannot  be  too  much 
insisted  on  ;  and  the  power  of  generating  heat  being  as  you  know  much 


156  TREATMENT   OF   THIS   CONDITION. 

diminished,  this  temperature  ought  not  to  be  below  70°,  and  in  bad 
cases  may  be  even  10°  higher.  Besides  attending  to  preserve  this 
"warmth  around  the  child,  benefit  often  accrues  from  the  employment 
of  the  hot  bath  once  or  twice  every  day,  at  a  temperature  of  100° 
Fahrenheit,  to  which  mustard  may  be  added  to  render  it  more  stimu- 
lating to  the  surface.  The  child  should  not  be  allowed  to  remain 
longer  than  five  minutes  in  the  bath,  and  should  be  enveloped  in  hot 
flannels  immediately  afterwards,  to  prevent  its  taking  cold.  The  back 
and  chest  should  be  rubbed  twice  or  oftener  every  day  with  a  stimu- 
lating liniment,  as  camphor  or  soap  liniment,  which  may  be  diluted  with 
a  little  oil,  if  it  be  too  irritating  to  the  skin.  If  the  child  be  very 
feeble,  stimulants  may  be  given ;  of  which  there  are  none  better  than 
the  compound  spirits  of  ammonia  or  ether  ;  or  the  spiritus  ammonise 
succinatus  ;  the  unpleasant  pungency  of  which  remedies  is  concealed  by 
milk  better  than  by  any  other  menstruum.  The  daily  employment  of  a 
gentle  emetic  of  ipecacuanha  has  in  some  instances  appeared  to  be  of 
service,  not  merely  by  relieving  the  air-tubes  of  any  mucus  that  may 
have  accumulated  there,  but  by  inducing  several  deep  inspirations,  and 
thus  aiding  the  complete  establishment  of  respiration.  As  the  child 
improves,  the  more  directly  stimulating  medicines  may  be  withdrawn, 
and  tonics  substituted  for  them,  among  which  few  are  better  than  the 
extract  of  cinchona.1  It  has  the  great  advantage  of  not  disordering 
the  bowels ;  a  point  of  no  small  importance  in  any  case  in  which 
diarrhoea  is  likely  to  occur.  In  some  cases  there  is  a  sluggishness  of 
the  bowels,  and  a  deficiency  in  the  secretion  of  bile ;  very  minute  doses 
of  the  Hydr.  c.  Creta  will  often  remedy  the  latter,  and  the  use  of  a 
soap  suppository  will  frequently  render  the  internal  employment  of  any 
purgative  needless.  The  child  should  be  put  to  the  breast  unless  it  be 
very  feeble,  but  in  that  case  should  not  be  allowed  to  exhaust  its 
strength  in  fruitless  attempts  to  suck.  It  will  be  better  to  draw  the 
breast,  and  give  the  child  its  mother's  milk  by  means  of  a  spoon  or 
from  a  bottle,  which  latter  plan  has  this  advantage,  that  while  it  costs 
the  child  but  little  effort  to  get  its  food,  we  avoid  the  risk  of  its 
forgetting  how  to  suck,  an  inconvenience  which  attends  the  use  of  the 
spoon  if  continued  for  any  length  of  time.  Artificial  feeding  is  not  at 
all  desirable  in  such  cases,  though  sometimes,  if  the  child  be  very  weak, 
it  may  be  necessary  at  first  to  give  a  few  drops  of  brandy  in  its  milk 
every  three  or  four  hours.  This  plan  of  treatment  must  be  patiently 
persevered  in,  nor  must  the  supervention  of  symptoms  of  an  apparently 
acute  character  induce  too  wide  a  deviation  from  it.  The  head  symp- 
toms in  particular  must  be  combated  cautiously,  lest  by  too  great  a 
solicitude  to  overcome  them  wTe  destroy  the  patient  rather  than  the 
disease. 

'  See  Formula  No.  3,  p.  45. 


157 


LECTUKE    XIV. 

Collapse  of  Lung  that  has  once  been  expanded — described  as  lobular  pneumonia 
by  various  writers — its  characters — symptoms  and  differences  from  true  pneumonia. — 
Observations  of  Bailly  and  Legendre. — Is  not  to  be  regarded  as  a  post-mortem  occur- 
rence.— Illustrative  cases. — Instances  of  its  occurrence  in  the  adult. — Similar  causes 
tend  to  produce  it  at  all  periods  of  life — hence  very  frequent  in  old  age. 

Induration  of  the  Cellular  Tissue — its  characters — remarkable  reduction  of  tempera- 
ture that  attends  it — appearances  after  death — condition  of  deficient  expansion,  or  of 
collapse  of  the  lung,  noticed  by  many  observers,  though  misunderstood  by  most,  is 
probable  cause  of  the  induration,  or  the  oedema  of  the  surface. 

The  condition  of  the  lungs  which  we  were  occupied  in  examining  at  the 
last  lecture  is  of  importance,  even  if  regarded  merely  as  a  congenital 
state,  the  result  of  nature  having  failed  in  the  attempt  to  establish 
respiration,  and  to  fit  the  child  thoroughly  for  the  new  mode  of  existence 
to  which  it  is  destined  after  birth.  But  its  claims  on  our  attention  are 
still  greater  when  we  bear  in  mind  the  possibility  of  its  occurrence  in 
consequence  of  a  variety  of  causes  operating  after  birth,  so  that  lungs 
once  permeable  to  air  may  cease  to  admit  it,  and  death  at  length  occur 
from  apnoea  without  any  serious  structural  change  having  taken  place 
in  the  organs  of  respiration. 

Appearances  supposed  to  be  the  result  of  pneumonia  had  long  attracted 
the  notice  of  writers  on  diseases  of  children,  by  the  wide  differences  which 
they  presented  from  those  which  inflammation  of  the  lungs  give  rise  to 
in  the  adult.  It  had  been  observed  that  infants  and  children  under  five 
years  of  age  often  died  after  presenting  some  of  the  symptoms  of  inflam- 
mation of  the  lungs,  such  as  cough  and  difficult  breathing,  together  with 
more  or  less  extensive  dulness  of  the  chest  on  percussion,  and  some  or 
other  of  the  auscultatory  signs  of  solidification  of  the  lung.  In  such 
cases  these  peculiar  morbid  appearances  were  especially  well  marked. 
But  while  they  seemed  to  prove  that  these  changes  in  the  lung  were 
the  consequences  of  pneumonia,  it  happened  not  infrequently  that  the 
fever  and  the  pneumonic  symptoms  underwent  a  great  abatement  before 
any  sign  of  approaching  death  appeared,  or  that  children  who  had  seemed 
to  die  worn  out  from  various  causes,  and  during  whose  lifetime  no 
indication  of  inflammation  of  the  lungs  had  existed,  presented  the  sup- 
posed anatomical  evidences  of  pneumonia  in  a  most  remarkable  degree. 
The  frequency  of  occurrences  of  this  kind  led  to  the  assumption  that 
pneumonia  was  an  extremely  frequent  concomitant  of  almost  all  the 
diseases  of  infancy  and  early  childhood, — that  this  pneumonia  was  very 
often  latent  (that  is  to  say,  that  it  did  not  manifest  its  existence  by 
those  symptoms  which  usually  attend  it),  and  lastly,  that  owing  to 
causes  which  were  differently  stated  by  different  observers,  it  gave  rise 
to  alterations  in  the  lung  very  dissimilar  from  those  which  it  occasioned 
in  the  adult. 

One  of  the  most  remarkable  peculiarities  of  this  supposed  infantile 
pneumonia  led  to  its  receiving  the  appellation  of  lobular  pneumonia, 


158  COLLAPSE  OP  LUNG  APTER  BIRTH — 

as  expressive  of  the  fact  that  it  did  not  attack  a  large  tract  of  lung,  or 
the  whole  of  a  lobe  at  one  time,  but  that  it  affected  isolated  lobules, 
which  might  be  seen  of  a  dark  colour,  solid,  often  depressed  below  the 
surrounding  parts,  and  sinking  in  water  if  detached  from  the  healthy 
/  tissue  in  the  midst  of  which  they  were  situated.  Sometimes  the  affection 
was  strictly  limited  to  a  single  lobule,  the  boundaries  of  which  could  be 
exactly  traced ;  and  though  it  often  happened  that  a  cluster  of  lobules 
was  thus  hard,  and  dark,  and  solid,  still  there  was  no  gradual  shading 
off  from  the  darker  to  the  lighter  parts,  so  that  it  was  evident  that,  in 
whatever  way  the  disease  extended,  at  any  rate  it  did  not  advance  by 
mere  continuity  of  tissue.  Sometimes  almost  the  whole  of  one  lobe 
was  thus  affected,  a  few  lobules  only  still  retaining  a  healthy  aspect,  and 
crepitating  under  the  finger,  and  it  often  happened  that  the  bronchi 
leading  to  it  were  full  of  mucus  or  pus,  while  at  other  times  there  was 
marked  congestion  of  the  lung,  and  in  the  midst  of  this  congested  tissue 
were  two  or  three  solid,  hepatized  patches.  All  these  circumstances,  as 
it  may  be  conceived,  variously  modified  the  morbid  appearances.  In 
the  last  case  the  lobular  pneumonia  was  thought  to  be  becoming  gener- 
alised, or,  in  other  words  the  inflammation  originally  limited  to  certain 
lobules  was  supposed  to  have  begun  to  extend  to  the  adjacent  tissues, 
constituting  a  kind  of  transition  state  between  lobular  and  lobar  pneu- 
monia. The  lower  edge  of  the  different  lobes,  the  whole  of  the  middle 
lobe  of  the  right  lung,  and  often  a  very  considerable  portion  of  the 
whole  of  one  or  other  lower  lobe,  were  also  sometimes  found  in  a  state, 
to  which,  among  other  names,  that  of  carnification  was  applied,  on 
account  of  its  close  resemblance  to  a  piece  of  muscular  tissue.  A  por- 
tion of  carnified  lung  showed  the  closest  possible  similarity  to  a  lung 
that  had  been  compressed  by  effusion  into  the  pleura.  It  was  dark, 
tough,  solid,  contained  no  air,  presented  a  smooth  surface  when  cut, 
yielded  a  small  quantity  of  bloody  serum,  when  pressed,  and,  indeed, 
seemed  almost  like  a  piece  of  flesh,  in  all  which  respects  it  resembled 
a  portion  of  lung  hepatized  by  lobular  pneumonia,  and  differed  from 
the  lung  of  the  adult  when  that  has  been  rendered  solid  by  inflamma- 
tion. 

The  course  of  the  disease  in  many  of  these  cases  during  the  life-time 
of  the  patient,  and  the  results  of  medical  treatment,  tended  to  enhance 
the  difficulties  which  the  above-described  anatomical  peculiarities  placed 
in  the  way  of  referring  lobular  pneumonia  to  the  same  category  of  affec- 
tions with  the  pneumonia  of  the  adult.  Venesection,  leeches,  and  mer- 
curials, the  ordinary  antiphlogistic  apparatus  in  the  pneumonia  of  the 
adult,  often  appeared  to  hasten  the  child's  death  ;  blisters  rarely  effected 
any  good,  and  the  blistered  surface  often  showed  a  remarkable  indisposi- 
tion to  heal.  On  the  other  hand,emetics  and  rubefacients  were  frequently 
of  service ;  a  stimulant  plan  of  treatment  was  almost  always  necessary 
at  an  early  period,  and  sometimes  seemed  to  be  required  almost  from 
the  outset  of  the  affection.  The  rapidity  of  the  changes  that  took 
place  in  the  physical  condition  of  the  lung  was  another  peculiarity  which 
rendered  the  nature  of  the  affection  still  more  obscure ,  for  where  air 
was  heard  entering  freely  on  one  day,  none  would  be  perceptible  on  the 
morrow,  but  percussion  of  that  part  of  the  chest  would  yield  a  sound  of 


MISTAKEN   FOR   LOBULAR   PNEUMONIA.  159 

complete  dulness.  On  the  other  hand,  it  happened  sometimes,  though 
much  less  often,  that  dulness  was  succeeded  just  as  quickly  by  resonance 
on  percussion,  and  that  breathing  became  distinctly  audible  where  on 
the  previous  day  no  sound  of  air  was  to  be  heard. 

Nothing  can  show  more  forcibly  the  influence  of  a  name,  than  the 
fact  that  this  condition  of  the  lungs  should  have  been  described  by  all 
writers  as  lobular  pneumonia,  and  that  its  symptoms  should  have  been 
attributed  to  inflammation,  while  yet  it  was  evident  from  the  concurrent 
testimony  of  every  one  that  neither  in  its  progress  nor  in  its  results  was 
it  similar  to  inflammation  of  the  lungs  in  the  adult,  much  less  identical 
with  it.  Having,  however,  once  been  called  pneumonia,  every  person 
continued  to  call  it  so,  though  often  with  a  full  recognition  of  its  pecu- 
liarities. Even  the  close  resemblance  which  the  lung  presented  to  foetal 
lung,  or  to  those  undilated  portions  which  are  characteristic  of  atelec- 
tasis, was  noticed  and  discussed  by  myself,  and  by  many  far  better 
observers,  apparently  without  a  suspicion  that  both  states  were  iden- 
tical. 

But  while  the  peculiarities  of  lobular  pneumonia  were  thus  generally 
commented  on,  it  seems  strange  that  no  one  should  have  had  recourse  to 
the  experiment  of  inflation  in  order  to  obtain  a  solution  of  some  of  the 
difficulties  that  existed  with  reference  to  its  nature.  This  oversight 
seems  the  more  extraordinary,  when  we  call  to  mind  that  this  very  means 
had  cleared  up  so  many  doubts  concerning  appearances  in  the  lungs  of 
new-born  infants,  which  had  once  been  supposed  to  be  the  result  of 
pneumonia  in  the  foetus,  or  of  some  arrest  of  developement.  At  length 
the  experiment  was  tried  by  MM.  Bailly  and  Legendre,1  and  though, 
as  in  the  old  tale  of  Columbus  and  the  egg,  the  thing  seems  so  obvious 
that  there  is  some  risk  of  our  undertaking  the  merit  of  those  who  were 
the  first  to  do  it,  it  must  not  be  forgotten,  that,  by  that  simple  means 
they  have  thrown  more  light  on  the  affections  of  the  lungs  in  infan- 
cy and  childhood,  than  all  the  writers  of  the  previous  ten  years  taken 
together. 

MM.  Bailly  and  Legendre  state  as  the  result  of  their  observations 
that  the  appearances,  to  which  the  name  of  lobular  pneumonia  has 
commonly  been  given,  are  in  reality  produced  by  an  occlusion  of  the 
pulmonary  vesicles.  This  occlusion,  say  they, — and  the  correctness  of 
this  opinion  is  now  universally  admitted, — is  due  to  the  inspiratory 
power  having  been  inadequate  to  overcome  that  elasticity  of  the  lung 
concerning  which  I  spoke  to  you  at  the  last  lecture  ;  while  it  is  in  many 
instances  favoured  by  the  accumulation  of  secretions  in  the  bronchi 
partly  obstructing  their  canal  and  interposing  a  more  than  ordinary 
obstacle  to  the  entrance  of  the  air.  Besides  this  cause  they  assign  a 
second,  in  the  direct  compression  of  the  air  vesicles  by  an  unusually 
congested  state  of  their  vessels ;  but  in  this  opinion,  in  which  I  former- 
ly coincided,  they  are  now  generally  believed  to  have  been  mistaken, 
and  the  congestion  is  probably  a  secondary  and  accidental  occurrence. 
Be  this  as  it  may,  however,    inflation  of  the  lung  will  in  either  case 

1  Nouyelles  Recherches  sur  quelques  Maladies  du  Poumon  ;  in  the  Arch.  Gdn.  deMe'd., 
Jan.,  Fevr.,  Mars,  1814. 


160  RESEARCHES   OP  BAILLY  AND   LEGENDRE. 

remove  the  solidity  of  the  lobules,  and  restore  them  almost  or  quite  to 
their  natural  appearance. 

It  may,  however,  be  objected  that  this  is  not  in  reality  a  morbid  con- 
dition of  the  lung,  but  that  it  is  only  the  effect  of  a  somewhat 
greater  degree  than  usual  of  that  collapse  of  the  organ  which  takes 
place  when  the  breath  leaves  the  body.  It  may  be  suggested  that  noth- 
ing more  is  needed  to  produce  the  complete  emptying  of  some  portions 
of  the  lung,  and  their  consequent  solidification,  than  the  resiliency  which 
they  retain  after  death,  coupled  with  the  pressure  of  theparietes  of  the 
thorax  upon  them.  The  possibility  of  this  condition  supervening  after 
death  cannot  be  denied,  but  still  it  may  safely  be  affirmed,  that  it  is  not 
usually,  nor,  indeed  frequently  a  post-mortem  occurrence.  The  fre- 
quency with  which  isolated  lobules  are  found  dark,  unaerated,  and  solid, 
while  all  the  surrounding  tissue  is  perfectly  healthy,  can  hardly  be 
accounted  for  on  the  supposition  that  the  state  comes  on  after  death. 
But  conclusive  evidence  is  afforded  by  the  physical  signs  of  solidifica- 
tion of  the  lung  being  observed  in  many  cases  in  which  this  condition 
is  found  after  death,  and  by  the  frequency  with  which  sudden  and  fatal 
dyspnoea  comes  on  in  the  course  of  various  affections  in  early  infancy, 
and  leaves  no  trace  of  its  cause  other  than  a  collapsed  state  of  a  consid- 
erable portion  of  the  lungs. 

A  little  girl  was  attacked,  when  a  month  old,  by  very  severe  diarrhoea 
which  lasted  for  three  weeks,  arid  then  left  her  greatly  exhausted  and 
much  emaciated.  No  return  of  the  purging  occurred,  and  the  child 
lived,  though  in  a  state  of  great  weakness,  till  she  was  five  months  old. 
For  the  last  five  weeks  of  her  life,  she  was  under  my  care,  and  some- 
times she  seemed,  for  a  day  or  two,  as  if  she  were  gaining  strength  and 
might  recover ;  but  these  signs  of  improvement  were  never  of  long  du- 
ration. Three  days  before  she  died,  her  breath  grew  suddenly  hurried ; 
the  dyspnoea  was  not  attended  with  any  cough,  but,  from  the  time  of  its 
coming  on,  the  child's  exhaustion  increased,  and  her  respiration  grew 
more  rapid  until  her  death. 

No  organ  showed  any  sign  of  disease,  but  all  presented  a  most  remark- 
able degree  of  anaemia.  Two-thirds  of  the  upper,  and  almost  the  whole 
of  the  lower  lobe  of  the  right  lung,  were  dark,  solid,  and  non-crepitant; 
and  a  few  lobules  of  the  left  lung  presented  the  same  appearance. — 
Inflation  restored  them  to  exactly  the  same  state  as  the  rest  of  the  lung. 
The  bronchi  were  preternaturally  pale,  and  contained  no  secretions.  It 
is  not  possible  to  say  why  the  child's  inspiratory  power  grew  too  feeble 
to  fill  the  lungs  at  one  moment  rather  than  at  another,  but  few  will  doubt 
that  it  had  become  so  just  at  the  time  when  the  dyspnoea  occurred.  A 
portion  of  the  lung  having  become  collapsed,  the  elastic  ribs  tended  to 
render  abortive  any  faint  effort  to  draw  in  more  air,  and  thus  the  vital 
flame  went  out  for  want  of  air  to  feed  it. 

Sometimes  the  occurrence  of  this  condition  is  long  preceded  by  indi- 
cations of  the  imperfect  performance  of  the  respiratory  functions,  but 
yet  they  go  on  sufficiently  to  keep  the  machinery  of  life  in  motion,  till 
some  trivial,  perhaps  some  inappreciable  cause, — a  draught  of  cold  air, 
a  little  over-exertion,  the  horizontal  posture  too  long  continued,  the 
customary  food  delayed  an  hour  beyond  the  usual  time, — sinks  them  so 
low  that  they  soon  cease  forever. 


CASES  OP   COLLAPSE   OF   THE   LUNG.  161 

Some  time  ago  I  saw  a  little  girl  ten  months  old,  who  had  lost  her 
mother  soon  after  her  birth,  and  had  been  indebted  to  a  stranger  for 
what  should  have  been  a  mother's  cares.  She  never  throve ;  her  chest 
presented  that  peculiar  malformation  commonly  called  pigeon-breast, 
and  the  diaphragm  drew  her  yielding  ribs  inwards,  and  thus  produced 
a  circular  constriction  around  the  base  of  the  thorax.1  But  though  she 
was  a  backward  child,  and  though  her  respiration  was  always  almost  as 
abdominal  as  that  of  a  new-born  infant,  there  was  no  definite  evidence 
of  disease  until  she  was  nine  months  old.  She  then  lost  flesh  rapidly, 
and  began  to  cough  without  having  had  any  previous  catarrh.  Her 
case  seemed  to  be  one  of  bronchial  phthisis. 

Four  days  before  she  died  her  breath  suddenly  became  much  op- 
pressed, and  her  cough  far  more  severe  than  it  had  been  before.  The  dys- 
pnoea rapidly  increased,  but  her  cough  soon  became  less  frequent.  A 
few  hours  before  her  death  her  lips  were  quite  livid ;  she  was  breathing 
from  80  to  86  times  in  the  minute,  the  abdominal  muscles  acting  most 
violently,  but  the  chest  being  scarcely  at  all  expanded.  Auscultation 
detected  nothing  more  than  some  rather  large  mucous  rale  in  the  lung. 

After  death  no  tubercle  was  found  in  any  organ,  but  large  portions 
of  both  lungs  presented  the  undilated  condition,  which  disappeared  en- 
tirely on  inflation.  The  bronchi  were  pale,  and  contained  very  little 
mucus,  but  the  right  side  of  the  heart  was  greatly  distended  with  coag- 
ulated blood,  which  its  thin,  pale,  and  flaccid  substance  had  evidently 
been  unequal  to  propel  with  the  requisite  vigour. 

The  imperfect  respiration  had  here  for  some  time  manifested  itself ; 
the  vital  powers  had  long  been  feeble;  nutrition  had  been  ill  performed, 
and  the  heart  itself  had  shared  in  the  general  feebleness,  till  at  length 
air  ceased  to  permeate  a  large  extent  of  the  pulmonary  substance,  and 
the  child  died  for  want  of  air  to  produce  the  requisite  changes  in  the 
blood. 

In  both  of  these  cases  the  lung  collapsed,  because  the  inspiratory 
powers  were  too  feeble  to  fill  the  minuter  vessels  with  air.  The  result 
is  the  same  if  the  obstacle  be  increased  as  if  the  power  be  diminished ; 
and  hence  the  supervention  of  this  state  of  lung  becomes  one  of  the 
most  perilous,  while  it  is  one  of  the  most  frequent,  complications  of  infan- 
tile bronchitis.  A  little  girl,  previously  quite  healthy,  was  seized  when 
ten  months  old  with  symptoms  of  acute  bronchitis,  a  suffocative  cough 
returning  in  paroxysms,  and  sometimes  followed  by  the  rejection  of  a 
muco-purulent  fluid.  The  symptoms  throughout  did  not  seem  to  allow 
of  depletion ;  but  ammonia,  with  decoction  of  senega  and  tincture  of 
squills,  and  other  expectorants  of  a  stimulating  kind,  were  given  with 
temporary  amendment.  The  child  did  not,  however,  appear  to  have 
undergone  any  marked  change,  either  for  better  or  worse,  except  that 
she  had  certainly  lost  both  flesh  and  strength,  when  coldness,  faintness, 
and  exceedingly  laboured  respiration,  suddenly  came  on,  under  which 
symptoms  she  died  in  the  course  of  twenty-four  hours. 

A  few  recent  adhesions  were  found  on  each  side  of  the  chest,  between 

1  A  very  interesting  explanation  of  the  mechanism  by  which  this  deformity  of  the 
chest  is  produced  is  given  by  MM.  Rilliet  and  Barthez,  op.  cit.  vol.  iii.,  p.  640. 

10 


162      CONDITION   PRODUCED   BY   SAME   CAUSES  AT   ALL  PERIODS   OF   LIFE. 

the  costal  and  pulmonary  pleura.  The  trachea  contained  a  large  quan- 
tity of  muco-purulent  matter,  and  the  same  secretion  abounded  in  the 
bronchial  tubes,  many  of  which  were  filled  by  it,  while  nowhere  did  air- 
bubbles  appear  intermixed  with  it.  There  was  some  congestion  of  both 
lungs,  especially  posteriorly;  the  upper  and  posterior  part  of  the  upper 
lobe  of  the  right  lung,  the  whole  of  the  middle  lobe,  and  the  posterior 
part  and  lower  edge  of  the  lower  lobe,  were  dark,  solid,  non-crepitant, 
and  depressed  below  the  adjacent  tissue.  The  same  state  existed  in  the 
wThole  inferior  third  of  the  upper  lobe,  and  the  lower  edge  of  the  lower 
lobe  of  the  left  lung.  On  inflating  the  lung,  most  of  these  parts  were 
restored  to  a  perfectly  natural  condition,  but  some  patches  still  remained 
less  dilated  than  the  others,  and  some  of  the  darker,  almost  violet- 
coloured  portions  of  the  lower  lobes  appeared  but  little  affected  by  it. 

But  you  may  naturally  inquire  whether  any  occurrence  of  a  similar 
kind  is  ever  met  with  in  the  adult,  since  there  is  certainly  no  such  pecu- 
liarity in  the  structure  of  the  lung  in  childhood  as  should  render  it  then 
exclusively  liable  to  a  morbid  process  from  which  at  all  other  ages  it  is 
exempt.  My  own  experience  would  not  enable  me  to  answer  this 
inquiry  ;  but  my  friend,  Dr.  Baly,  has  communicated  to  me  the  particu- 
lars of  three  cases  in  which  he  found  large  portions  of  the  lung  in  the 
adult  presenting  the  characters  that  we  have  been  studying  in  the  child, 
and  like  it  resuming  a  natural  appearance  on  the  insufflation  of  air  into 
the  bronchi.  The  patients,  in  all  of  these  cases,  died  of  fever,  attended 
with  dysenteric  symptoms ;  and  for  some  days  before  their  death  were 
in  a  state  of  great  exhaustion,  such  as  appeared  to  indicate  the  free 
employment  of  stimulants.  In  two  of  the  cases  extreme  dyspnoea 
occurred  some  days  previous  to  death ;  but  though  the  chest  lost  its 
resonance  in  the  situation  of  the  affected  parts  of  the  lung,  and  the 
breathing  there  was  deficient,  yet  the  minute  crepitation  of  pneumonia 
was  not  detected  in  either  case,  but  merely  some  large  mucous  rale.  In 
addition  to  extensive  disease,  which  in  each  instance  existed  in  the  intes- 
tines, this  collapsed  condition  of  portions  of  the  lung  was  found ;  un- 
connected with  any  disease  of  those  organs  in  one  of  the  cases,  combined 
with  the  effusion  of  tenacious  mucus  in  the  bronchi  leading  towards  the 
collapsed  portions  in  a  second,  and  associated  with  true  pneumonia  and 
a  state  of  red  or  yellow  hepatization  of  other  parts  in  a  third.1 

But  these  are  by  no  means  isolated  cases  ;  for  it  would  seem  as  if  in 
some  diseases  which  are  attended  with  much  depression  of  the  vital 

1  The  minute  accuracy  of  Dr.  Baly's  description  induces  me  to  subjoin  the  following 
particulars  of  one  of  the  examinations,  as  he  allows  me  to  extract  them  from  his  case- 
book : — "  No  effusion,  lungs  healthy,  except  in  lower  and  posterior  fourth  of  right 
inferior  lobe,  which  is  of  a  dark  purple  colour,  is  depressed  somewhat  below  the  level  of 
other  parts,  does  not  crepitate,  feels  solid,  but  flexible  and  tough,  almost  leathery,  and 
sinks  quickly  in  water  :  the  part  having  these  characters  is  distinctly  defined  by 
boundaries  of  lobules.  The  whole  lung  being  inflated,  the  part  just  described  receives 
air  with  greater  difficulty  than  the  other  parts,  but  at  length  becomes  distended,  lobule 
by  lobule,  and  assumes  the  same  pale  red  colour  as  the  rest  of  the  lungs.  The  change 
takes  place,  as  has  been  stated,  lobule  by  lobule,  separate  lobules  appearing  suddenly 
of  the  paler  colour,  not  merely  at  the  margins  of  the  dark  mass,  but  also  in  this  centre. 
On  cutting  through  the  lungs  and  tracing  the  bronchi,  it  is  found  that  the  ramifications 
of  those  tubes  which  go  to  the  dark,  contracted,  and  condensed  parts,  are  filled  up  with 
tough  mucus,  from  which  those  going  to  other  parts  are  free." 


COLLAPSE   OF   THE   LUNG   IN   THE   ADULT.  163 

powers,  this  collapse  of  the  lungs  were  by  no  means  unusual.  To  ad- 
duce but  one  illustration  of  this,  it  may  be  mentioned  that  M.  Louis1 
found  in  nineteen  out  of  forty-six  post-mortem  examinations  of  patients 
who  had  died  of  typhoid  fever,  a  condition  of  the  lungs  which  he  calls 
"  carnification,"  and  which  it  is  evident  (although  he  did  not  try  the  effect 
of  inflation)  was  identical  with  the  state  so  frequent  in  the  child.  He 
describes  the  parts  thus  affected  as  of  a  deep  purple  red,  having  lost  the 
natural  suppleness  of  the  lung,  being  solid,  and  sinking  in  water :  they 
were,  moreover,  tougher  than  healthy  lung :  if  divided,  the  section 
became  covered  with  a  reddish  fluid,  perfectly  destitute  of  air,  while 
the  tissue  neither  resembled  that  of  healthy  lung,  nor  presented  the 
peculiar  granular  appearance  characteristic  of  lung  in  the  second  stage 
of  pneumonia.  More  recently,  too,  Dr.  Grairdner,  of  Edinburgh,  in 
his  very  important  essays2  on  the  "  Pathological  Anatomy  of  Bronchi- 
tis," &c.  has  mentioned  this  condition  of  the  lungs  as  having  been  of  fre- 
quent occurrence  during  the  epidemic  fever  of  1847. 

It  is  true,  however,  that  in  these  cases  the  condition  of  the  lungs 
was  merely  superadded  to  other  lesions  in  themselves  adequate  to  occa- 
sion the  patient's  death ;  and  hence,  though  interesting  to  the  mere 
pathologist,  it  yet  loses  much  of  its  value  in  the  eyes  of  the  practical 
physician.  But  it  will  not  seem  to  you  that  too  much  stress  has  been 
laid  on  this  state,  if  it  should  appear  that  whenever  the  power  of  the 
inspiratory  muscles  is  much  diminished  there  is  a  tendency  to  its  super- 
vention, so  that  it  alone  may  be  the  cause  of  death ;  and  this,  which  I 
have  put  hypothetically,  really  does  occur  in  old  age. 

The  term  second  childhood  is  not  a  mere  figure  of  speech,  expressive 
solely  of  the  decay  of  the  mental  powers,  by  which  the  evening  of  life 
is  obscured  and  made  like  the  twilight  of  the  mind  in  early  infancy,  but  it 
is  in  many  points  the  expression  of  a  physical  truth.  Thus  as  old  age 
creeps  on,  and  the  nutrition  is  no  longer  adequate  to  supply  the  waste, 
the  respiration  loses  the  character  which  it  presented  in  the  adult,  and 
the  extremes  of  life  in  this  respect  present  a  close  resemblance  to  each 
other.  The  muscles  of  the  chest  are  no  longer  strong  enough  to  dilate 
it  fully ;  the  diaphragm  becomes  as  it  was  in  early  infancy,  the  princi- 
pal inspiratory  muscle,  and  the  vertical  diameter  of  the  thorax  is  that 
in  which  its  chief  enlargement  takes  place.  The  ear  applied  to  the 
chest  no  longer  detects  the  puerile  breathing  of  youth,  nor  the  clear 
vesicular  murmur  of  manhood ;  but  the  respiration  is  coarser,  sometimes 
almost  bronchial.  There  is  not  occasion,  as  in  infancy,  for  more  rapid 
breathing  to  maintain  the  high  activity  of  the  vital  processes,  but  the 
worn-out  machinery  needs  to  be  put  in  motion  more  frequently  than 
in  the  adult,  in  order  to  obtain  oxygen  enough  to  support  existence ; 
and,  accordingly,  MM.  Hourman  and  Dechambre3  found  the  average 
frequency  of  the  respiration  in  255  old  women  at  the  Salpetriere  to  be 
21.79  in  the  minute,  while  in  some  whose  frame  seemed  most  decayed 

1  Recherches  sur  la  Gastro-enterite.     8vo.  Paris,  1829  ;  tome  i.,  pp.  3G1-364. 

2  Reprinted  from  the  Monthly  Journal  of  Medical  Sciences  for  1850  and  1851. 

3  The  above  facts  with  respect  to  the  respiration  in  the  aged  are  derived  from  the 
interesting  papers  of  MM.  Hourman  and  Dechambre,  in  the  Arch,  de  Med.  for  1835  and 
1836.     See  especially  the  number  for  Nov.,  1835. 


64  INDURATION    OF   THE   CELLULAR    TISSUE. 

it  was  far  more  rapid.  Just  as  in  infancy,  too,  so  in  old  age,  these  respi- 
ratory movements  are  most  irregular.  Sometimes  the  parietes  of  the 
thorax  continue  for  a  long  time  motionless,  and  then  there  succeed 
a  series  of  rapid  movements,  while  at  other  times  the  intervals  between 
the  inspirations  are  irregular,  but  the  inspiratory  movements  are  of  the 
same  intensity  and  duration.  Here  then,  without  pursuing  the  compar- 
ison further,  we  have  ample  proof  of  the  many  points  of  resemblance 
between  the  physiological  condition  of  the  respiratory  function  in  early 
life  and  in  old  age.  The  respiratory  organs,  too,  in  their  pathological 
state,  present,  as  might  be  expected,  the  same  resemblance ;  and  accor- 
dingly MM.  Hourman  and  Dechambre1  notice  a  state  in  which  the  pul- 
monary parenchyma  is  of  a  very  deep,  sometimes  almost  of  a  blue 
colour,  or  nearly  black,  non-crepitant,  and  presenting  a  smooth  surface 
on  a  section  of  it  being  made.  The  lung  thus  altered  is  often  remark- 
ably tough,  almost  like  Indian  rubber ;  while  under  pressure,  a  viscous 
fluid,  generally  of  a  reddish  colour,  and  containing  no  air-bubbles,  exudes 
from  it.  The  idea  of  inflating  the  lung  had  not  occurred  to  these  ob- 
servers ;  but  they  remark,  that  if  portions  of  lung  presenting  these 
characters  be  dried,  the  air-cells  have  a  tendency  to  re-appear  without 
having  undergone  any  other  change  than  a  well-marked  contraction. 

I  have  dwelt  long  on  this  pathological  condition,  though  I  think  not 
longer  than  its  importance  demands,  because  we  shall  find  that  in  some 
form  or  other  it  presents  itself,  modifying  the  symptoms,  determining 
the  prognosis,  and  influencing  the  treatment  of  almost  all  the  affections 
of  the  lung  in  early  infancy. 

We  shall  pass  to  the  study  of  some  of  these  diseases  at  the  next  lec- 
ture ;  but,  before  doing  so,  may  notice  an  affection  about  whose  nature 
much  controversy  has  arisen,  but  to  which,  thanks  to  the  researches 
of  MM.  Bailly  and  Legendre,  we  may  now  assign  a  place  as  one  of  the 
results  of  the  imperfect  expansion  of  the  lungs,  and  of  the  consequently 
incomplete  performance  of  the  respiratory  functions.  Though  very 
rare  in  this  country,  induration  of  the  cellular  tissue  is  extremely 
common  in  the  foundling  hospitals  of  the  Continent,  where  so  many 
causes  contribute  to  depress  the  new-born  infant's  feeble  powers. 
The  children  in  whom  it  occurs  are  usually  weakly,  not  seldom  pre- 
mature, and  its  first  symptoms  generally  appear  between  the  first  and 
fifth  day  after  birth,  though  occasionally  they  do  not  come  on  till  later. 
In  many  instances  a  livid  redness  of  the  whole  surface  is  obvious  from 
birth ;  but  the  appearance  of  a  circumscribed  hard  spot  on  one  or  other 
extremity,  or  on  some  prominent  part  of  the  face,  as  the  end  of  the 
chin,  or  the  cheek  bone,  is  the  first  sign  of  the  commencement  of  this 
affection.  Other  spots  of  a  similar  kind  are  soon  discovered  on 
different  parts  of  the  surface  ;  and  the.  body  generally,  and  the  hardened 
spots  in  particular,  are  found  to  present  a  temperature  much  below  the 
natural  warmth  of  the  body.  It  appears,  indeed,  from  M.  Roger's 
researches,2  that  a  general  reduction  of  the  temperature  precedes  the 
induration,  or,  at  least,  exists  in  a  very  marked  degree,  while  the 

1  Op.  cit.  Mars  1836,  p.  272. 

2  Op.  cit.  pp.  124,  151.  * 


INDURATION   OF   THE   CELLULAR   TISSUE.  165 

induration  is  still  extremely  slight.  The  sinking  of  the  temperature 
and  the  extension  of  the  induration  advance  together,  and  the  warmth 
of  the  surface  may  eventually  fall  from  100°  to  90°,  80°,  or  even 
lower.  If  the  induration  become  very  extensive,  it  affects  the  integu- 
ments of  the  chest  and  abdomen,  as  well  as  the  extremities,  and  tlie 
body  feels  cold  and  stiff,  as  though  it  were  frozen. 

This  condition  is,  as  might  be  expected,  attended  with  great  impair- 
ment of  the  general  health.  Children  suffering  from  it  are  extremely 
weak,  often  too  weak  to  suck ;  their  pulse  is  very  small,  their  respiration 
abdominal,  and  their  cry  faint  and  whimpering,  wholly  unlike  that  of 
a  healthy  infant.  In  some  of  the  worst  cases,  too,  a  bloody  fluid  is 
discharged  in  considerable  quantity  from  the  nose  and  mouth.  If  the 
indurated  parts  be  punctured,  a  small  quantity  of  reddish  serum  escapes 
from  them,  though  generally  without  much  diminution  of  their  previous 
hardness. 

If  the  induration  be  at  all  general,  death  almost  invariably  takes 
place ;  and  so  great  is  the  fatality  of  the  affection,  that,  including  even 
slight  cases,  five-sixths  of  those  children  who  are  attacked  by  it  in  the 
hospitals  of  Paris,  die.  In  very  slight  cases,  however,  if  the  infant  be 
at  once  placed  in  favourable  circumstances,  recovery  need  not  be 
despaired  of. 

The  hardness  of  the  surface  still  persists  after  death,  and  the  absence 
of  any  peculiarity  in  the  effused  serum,  or  of  any  sign  of  active  disease, 
left  writers  generally  in  much  perplexity  as  to  its  cause.  The  venous 
system  is  usually  found  gorged  with  fluid  blood,  and  this  congestion  is 
often  apparent  in  the  cerebral  vessels,  as  well  as  in  those  of  the 
abdominal  viscera,  particularly  the  liver.  Both  the  thorax  and  abdo- 
men also  frequently  contain  a  quantity  of  serum,  often  tinged  with 
blood, — effusions  which  are  evidently  of  a  passive  nature,  since  they 
are  unattended  with  any  trace  of  inflammation  either  of  the  pleura 
or  peritoneum.  None  of  the  viscera  present  any  morbid  appearances 
of  half  so  much  importance  as  those  which  are  met  with  in  the  lungs, 
a  very  great  part  of  which  displays  those  changes  to  which  your 
attention  has  already  been  directed  as  characteristic  of  their  deficient 
expansion.1  This  condition  of  the  lungs  had  been  noticed  and'  most 
carefully  described  many  years  ago,  as  one  of  the  most  striking 
attendants  on  induration  of  the  cellular  tissue.     It  was  thought  by 

1  The  observations  of  J.  A.  Troccon,  in  his  dissertation,  "Sur  la  maladie  connue  sous 
le  nom  d'endurcissement  du  tissu  cellulaire,"  4to.  Paris,  1814,  are  especially  remark- 
able, since  he  not  only  described  with  accuracy  the  physical  condition  of  the  lungs,  but 
even  tried  the  experiment  of  inflating  them,  in  order  to  prove  that  they  were  not,  as  had 
been  erroneously  supposed,  in  a  state  of  gangrene.  He  says — "  J'ai  insuffle"  ensuite  de 
l'air  dans  les  poumons  par  la  trach£e,  aussitot  le  couleur  noire  qui  e"tait  a  leur  base  s'est 
changee  en  une  couleur  rouge  claire,  laquelle  s'est  etendue  de  proche  enproche  a  mesure 
que  je  continuais  ces  insufflations."  After  removing  a  ligature  which  he  had  applied 
around  the  veins  and  allowing  the  escape  of  the  blood  with  which  the  heart  and  lungs 
were  gorged,  he  resumed  the  inflation  of  the  lungs,  and  "les  organes  de  la  respiration 
ont  6te  presque  de  suite  dans  un  6tat  absolument  naturel,  et  aussi  beaux  que  ceux  Ton 
voit  pendus  devant  nos  boucheries." — pp.  37-8. 

It  seems  strange  that  neither  M.  Troccon  nor  subsequent  observers  perceived  the  full 
bearing  of  these  experiments  till  similar  ones  were  instituted  by  MM.  Bailly  and 
Legendre. 


166  TREATMENT   OF   INDURATION    OF   THE   CELLULAR   TISSUE. 

some  of  those  who  described  it  to  be  the  result  of  pneumonia  ;  while 
other  observers,  justly  insisting  on  the  absence  of  the  other  effects  of 
inflammation  of  the  pulmonary  tissue,  yet  drew  the  attention  of  patho- 
logists too  much  away  from  the  chest,  where  the  clue  to  the  solution  of 
the  question  as  to  the  cause  of  the  affection  was  to  be  found,  had  they 
but  known  how  to  use  it.  We,  however,  are  aware  that  those  appearances 
once  thought  to  be  the  result  of  pneumonia  are  in  reality  due  to  the 
unexpanded  condition  of  the  lung;  and  we  can  understand  how  it  may 
happen,  if  children  be  exposed  to  cold  immediately  after  birth,  and  then 
transferred  to  the  ill-ventilated  wards  of  a  foundling  hospital,  and  there 
fed  with  food  far  other  than  that  which  nature  destined  for  them,  that 
respiration  may  be  but  very  imperfectly  established  ;  that  their  tem- 
perature may  consequently  fall,  and  the  blood  flowing  in  part  through 
the  unclosed  foetal  passages  may  stagnate  in  its  course,  may  give  rise 
to  passive  effusions  into  the  great  cavities  of  the  body,  and  to  an 
anasarcous  swelling  of  the  surface.  There  are,  it  is  true,  some  peculia- 
rities in  this  form  of  oedema,  but  not  such  as  to  invalidate  the  above 
explanation  of  the  cause  to  which  it  is  due. 

The  treatment  of  this  affection  implies  the  removal  of  every  cause 
likely  to  induce  it.  Hence  warmth  stands  foremost  as  a  curative  as  well 
as  a  preventive  measure.  The  warm  bath  may  be  resorted  to  as  a  means 
of  raising  the  child's  surface  to  a  proper  temperature,  provided  its 
extreme  weakness  do  not  contra-indicate  that  measure.  Gentle  friction 
with  warm  oil  is  a  means  which  has  been  tried  for  this  purpose  with 
advantage.  The  child  should  be  nourished  with  breast-milk,  even  if  it 
be  too  feeble  to  suck,  and  stimulants,  of  which  white-wine  whey  is  a  very 
good  one,  will  in  many  instances  be  needed.  Defective  respiration 
being  the  ultimate  source  of  all  the  symptoms,  the  main  principles  of 
all  your  treatment  must  be  the  same  as  have  been  already  laid  down  for 
your  guidance  in  cases  of  atelektasis  of  the  lung ;  and  these  it  can  hardly 
be  necessary  to  recapitulate. 

I  should  have  said  more  about  this  affection,  its  nature  and  treatment, 
if  it  were  one  with  which  you  were  likely  to  meet  often  ;  but  in  conside- 
ration of  its  extreme  rarity  in  this  country,  I  may  perhaps  be  excused 
for  passing  it  over  with  this  cursory  notice. 


LECTURE    XV. 

Inflammatory  Affections  of  the  Respiratory  Mucous  Membrane — comparative 
rarity  of  catarrh  during  the  first  weeks  of  life. — Coryza — simple  and  pseudo-mem- 
branous, or  malignant. — Catarrh,  causes  adding  to  its  importance  in  early  life — its 
treatment — danger  of  bronchitis  or  pneumonia. 

Post-mortem  appearances  of  Bronchitis — redness  of  the  membrane — nature  of  the  con- 
tents of  the  bronchi — dilatation  of  their  cavity. — Extension  of  the  inflammation  to  the 
lining  of  the  pulmonary  vesicles,  producing  vesicular  bronchitis. 

State  of  the  lungs  in  bronchitis — frequency  of  congestion — carnification  of  some  lobules 
— possible  extension  of  inflammation  to  the  pulmonary  tissue,  producing  lobular  pneu- 
monia— suppuration  of  these  patches  producing  vomicae. 

Although  two  lectures  have  already  been  devoted  to  the  pathology 
of  the  respiratory  organs,  yet,  until  to-day,  we  have  not  been  able  to 
commence  the  study  of  their  special  diseases. 


AFFECTIONS   OF   THE   RESPIRATORY   MUCOUS   MEMBRANE — CORYZA.       167 

They  may  be  divided  into  the  three  grand  classes — of  the  inflamma- 
tory, the  nervous,  and  those  which  result  from  morbid  deposits.  We 
will  examine  these  in  the  order  in  which  I  have  enumerated  them. 

At  every  age  inflammatory  affections  of  the  respiratory  mucous 
membrane  exceed  all  others  in  frequency  ;  and  even  when  the  pulmonary 
substance  becomes  eventually  involved,  it  is  often  by  the  extension  to  it 
of  mischief  which  began  in  the  mucous  membrane.  But  in  infancy 
and  childhood  this  is  pre-eminently  the  case,  for  the  delicate  and  highly 
vascular  lining  of  the  respiratory  organs  resists  but  feebly  the  influence 
of  noxious  impressions  from  without,  while  it  sympathises  most  acutely 
with  many  morbid  processes  within. 

This  extreme  susceptibility  of  the  mucous  membrane  of  the  respira- 
tory organs  in  childhood  renders  its  disorders  of  very  frequent 
occurrence,  while  we  are  compelled  to  study  closely  the  signification  of 
symptoms  that  may  betoken  disturbance  from  such  various  causes. — 
Something  of  this  sympathy  with  the  affections  of  other  parts  exists 
even  in  the  adult,  as  we  may  see  exemplified  in  the  cough  that  attends 
upon  affections  of  the  liver,  but  in  the  child  the  sympathetic  disorder  of 
the  respiratory  mucous  membrane  is  vastly  more  frequent ;  and  nurses, 
taught  by  experience,  will  speak  to  you  about  a  tooth  cough,  a  stomach 
cough,  a  worm  cough  ;  while  you  will  soon  find  for  yourselves  that  the 
intestinal  mucous  membrane  is  seldom  affected  without  that  of  the 
respiratory  apparatus  suffering  too. 

It  is  a  curious  fact,  however,  to  which  Professor  Jorg  of  Leipsic1  was 
the  first  person  to  call  attention,  that  this  extreme  susceptibility  of  the 
lining  of  the  respiratory  apparatus  does  not  exist  to  the  same  degree 
during  the  first  month  or  two  of  life  as  it  does  afterwards.  The  exposure 
of  an  infant  two  or  three  weeks  old  to  a  low  temperature  or  to  a  vitiated 
air,  will  be  followed  by  disturbance  of  the  function  of  the  liver,  and 
the  occurrence  of  jaundice ;  or,  perhaps,  the  muscular  power  may  be 
so  far  depressed  as  to  render  the  child  incapable  of  taking  a  full 
inspiration,  so  that  its  lungs  collapse,  and  it  dies  from  disorder  of  the 
respiratory  organs,  but  without  the  cough  or  bronchitic  symptoms, 
which  would  not  fail,  if  it  were  a  little  older,  to  announce  the  irritation 
of  the  raucous  membrane  of  the  air-tubes.  Why  this  is  so  I  do  not 
know,  but  I  suppose  it  to  be  the  result  of  the  generally  feeble  vitality 
which  renders  the  lining  of  the  bronchi  less  susceptible  ;  just  as  that 
of  the  intestine  also  seems  to  be,  at  the  same  period,  since,  while 
constipation  is  frequent,  diarrhoea  is  comparatively  rare  during  the  first 
two  months  of  life. 

The  mucous  membrane  of  the  nares,  however,  has  not  by  any  means 
this  insensibility,  and  coryza  is  an  affection  most  frequent,  and  most 
important  during  the  first  two  months  of  life,  when  the  other  forms  of 
catarrh  are  comparatively  rare. 

This  affection,  in  its  most  frequent  form,  is  a  source  of  discomfort 
rather  than  of  danger.  Its  most  prominent  symptom  has  given  rise  to 
its  vulgar  name  of  athe  snuffles;"  for  the  mucous  membrane  of  the 
nares  being  swollen,  the  child  is  no  longer  able  to  breathe  through  its 

1  Handbuch  der  Kinderkrankheiten,  8vo.  Leipsig,  1836,  p.  531. 


168  CORYZA   MALIGNA. 

mouth,  and  its  difficult  inspirations  are  attended  with  a  peculiar 
snuffling  noise,  which,  during  sleep,  sometimes  amounts  to  a  complete 
snore.  As  in  common  catarrh,  the  secretion  from  the  membrane  is  at 
first  suppressed,  afterwards  it  flows  in  an  increased  quantity,  and  then 
at  length  it  is  altered  in  character,  and  becomes  thicker  and  puriform  ; 
and  then  it  sometimes  dries  and  forms  crusts  about  the  nostrils,  which 
interfere  greatly  with  free  respiration,  and  cause  the  child  much  annoy- 
ance. At  the  outset  there  is  often  a  degree  of  heat  of  skin  and  febrile 
disturbance,  but  these  symptoms  soon  subside,  and,  with  the  exception 
of  the  snuffling  respiration,  the  child  seems  quite  well.  If  the  attack 
be  more  severe,  however,  it  may  occasion  a  good  deal  of  suffering,  for 
if  respiration  through  the  nose  be  very  much  impeded  or  altogether 
prevented,  the  child  is  rendered  unable  to  suck,  and  so  soon  as  it  has 
seized  the  nipple  and  begun  to  draw  the  milk,  it  is  compelled  to  leave  it 
in  a  state  of  threatening  suffocation.  Its  distress,  too,  is  further 
increased  by  the  circumstance  that  its  mouth,  being  constantly  kept 
open  in  order  to  breathe,  the  tongue  and  throat  become  extremely  dry, 
and  deglutition,  even  when  the  child  is  fed  with  a  spoon,  is  often  attended 
with  difficulty.  .  Any  such  severity  of  the  disease,  however,  is  very  un- 
usual, though  such  cases  do  sometimes  occur,  and  even  prove  fatal ;  the 
difficulty  of  breathing  and  sucking,  together,  wearing  out  the  patient. 
When  this  event  occurs,  something  more  seems  to  exist  than  a  simple 
inflammation  of  the  Schneiderian  membrane,  since  it  either  secretes  a 
very  tenacious  mucus  in  extreme  abundance,  or  becomes  coated  with 
false  membrane  which  sometimes  extends  even  to  the  tonsils  and  palate. 
Cases  of  this  kind  are  usually  associated  with  extreme  depression  of 
the  vital  powers,  and  have  received  on  this  account  the  name  of  coryza 
maligna.  In  the  Foundling  Hospitals  of  the  continent  this  malignant 
coryza  is  not  very  uncommon.  I  have  never  but  once,  however,  seen 
anything  approaching  to  it  in  severity,  except  where  it  has  occurred  as 
a  complication  of  scarlatina.  In  that  instance,  a  little  boy,  six  months 
old,  was  brought  to  me  on  the  25th  of  October,  1842.  His  health  had 
been  good  until  the  20th,  when  he  became  hoarse ;  on  the  22d  this 
hoarseness  had  much  increased,  and  he  became  unable  to  suck,  since 
which  time  he  had  continued  to  grow  worse.  When  I  saw  him  his  skin 
was  warm,  face  rather  flushed,  eyes  watering,  and  a  thick  ropy  mucus 
obstructed  his  nostrils.  He  cried  with  a  suppressed  but  squeaking 
voice,  and  breathed  with  a  peculiar  wheezing  noise,  though  air  entered 
the  chest  unattended  with  any  rale.  The  child  was  unable  to  suck,  and 
even  when  he  drank  from  a  cup  the  fluid  often  returned  through  his 
nose.  The  inside  of  the  mouth  was  very  red,  and  the  tonsils  and  soft 
palate  were  especially  so.  The  mouth  was  full  of  an  extremely  tenacious 
mucus,  which  it  was  necessary  from  time  to  time  to  take  out  with  the 
hand. 

A  lotion  was  injected  up  the  nostrils,  composed  of  5j-  of  alum  to  *ij. 
of  water,  with  great  relief  to  the  child,  the  secretion  from  the  nares 
becoming  more  decidedly  puriform,  but  less  adhesive  ;  and  the  child 
became  able  to  suck  a  little.  On  the  28th,  however,  the  child's  powers 
seemed  much  depressed ;  it  sucked  eagerly,  for  the  secretion  from  the 
nose  had  become  almost  watery,  but  it  swallowed  with  much  difficulty. 


TREATMENT   OP   CORYZA.  169 

A  layer  of  false  membrane  of  a  yellowish-white  colour  had  now  appeared 
on  the  soft  palate  and  back  of  the  hard  palate,  and  on  the  tonsils. 

A  lotion  of  three  grains  of  the  nitrate  of  silver  to  an  ounce  of  water 
was  applied  to  the  back  of  the  throat,  and  a  mixture  of  the  extract  of 
bark  with  ammonia  was  given  every  six  hours.  On  the  first  of  Novem- 
ber the  child  was  better,  could  both  swallow  and  suck  well,  and  the 
false  membrane  had  entirely  disappeared  from  the  mouth ;  but  the 
palate  was  still  red,  and  presented  some  broad  superficial  patches  of 
ulceration.  The  subsequent  recovery  was  tardy,  but  the  immediate 
danger  was  over,  and  no  relapse  occurred. 

The  simple  coryza,  calls,  as  I  have  already  observed,  for  but  little 
treatment,  and,  indeed,  treatment  appears  to  exert  but  little  influence 
over  it.  It  is  desirable,  however,  if  there  be  much  difficulty  in  breathing, 
that  the  child  be  taken  from  the  breast,  though  it  may  still  be  fed  with 
its  mother's  milk  by  means  of  a  spoon,  since  the  fruitless  efforts  to  suck 
aggravate  its  sufferings,  and  should  therefore  be  prevented.  If  heat  of 
skin  and  other  indications  of  fever  attend  its  onset,  some  mild  diapho- 
retic medicine,  with  a  few  drops  of  ipecacuanha  wine,  may  be  given  \l 

(No.  8.) 
1  R  Liq.  Am.  Acet.  gj. 
Vin.  Ipecac.  TTLxvj. 
Pot.  Nitratis,  gr.  viij. 

Mist.  Amygdalae,  gvij.     M.     gj.  4tis.  horis. 
For  a  child  six  months  old. 

attention  must  be  paid  to  the  state  of  the  bowels,  and  in  the  course  of 
ten  days  or  a  fortnight  the  infant  will  be  found  again  breathing  quietly, 
and  the  disease  will  have  subsided.  As  the  secretion  becomes  thicker, 
care  must  be  taken  to  prevent  its  accumulating  and  drying  at  the  open- 
ing of  the  nostrils,  by  which  it  would  cause  serious  discomfort  to  the 
child.  In  the  malignant  variety  of  the  disease  local  as  well  as  general 
treatment  becomes  necessary.  The  tendency  to  the  formation  of  false 
membrane  in  the  nares  must  be  combated  by  injections  of  alum  or 
nitrate  of  silver,  while  the  condition  of  the  fauces  must  be  watched  as 
narrowly  as  that  of  the  nares,  and  similar  applications  must  be  made  to 
them  on  the  appearance  of  any  unusual  redness  there,  since  such  increase 
of  vascularity  is  only  the  first  stage  of  that  process  which  would  issue 
in  the  exudation  of  false  membrane.  At  the  same  time,  a  general  tonic 
plan  of  treatment  will  be  called  for,  and  care  will  be  needed  to  ensure 
the  child's  taking  a  proper  quantity  of  nutriment,  since  its  powers  of 
sucking  and  of  deglutition  will  in  all  probability  both  be  impaired. 

Cases  are  sometimes  met  with,  in  which  coryza,  though  not  of  a 
severe  kind,  is  troublesome  by  its  continuance  for  weeks  together.  This 
chronic  coryza  is,  I  believe,  almost  always  connected  with  a  syphilitic 
taint.  I  have  on  several  occasions  met  with  it  when  there  were  not 
above  one  or  two  spots  of  copper-coloured  eruption  to  mark  its  charac- 
ter ;  and  a  few  instances  of  it  have  come  under  my  notice  in  which  no 
positive  evidence  of  venereal  taint,  either  past  or  present,  could  be 
obtained,  but  which  nevertheless  got  well  under  the  use  of  small  doses 
of  Hydrarg.  c.  Creta. 


170  CATARRH — ITS   IMPORTANCE  IN  EARLY   LIFE. 

With  the  increasing  age  of  the  infant  there  is  a  growing  liability  to 
catarrh,  and  during  the  period  of  dentition  the  susceptibility  of  the 
mucous  membrane  of  the  respiratory  organs  appears  to  have  attained 
its  maximum.  Slight  variations  of  temperature  now  induce  catarrhal 
seizures  ;  or  even,  independently  of  any  such  exciting  cause,  the  mere 
approach  of  a  tooth  towards  the  surface  of  the  gum  often  gives  rise  to 
its  symptoms,  which  subside  when  the  source  of  irritation  ceases.  Such 
attacks  often  alternate  with  attacks  of  diarrhoea,  or  the  two  coexist ; 
the  symptoms  of  disturbance  of  the  intestinal  mucous  membrane  pre- 
dominating at  one  time,  those  of  disturbance  of  the  respiratory  mem- 
brane at  another.  The  preponderance  of  one  or  the  other  affection  seems 
much  to  depend  on  atmospheric  causes  ;  and  children  who,  during  the 
months  of  June,  July,  August,  and  September,  would  suffer  from  diar- 
rhoea, will,  under  precisely  similar  circumstances  in  the  earlier  months 
of  spring,  or  the  later  months  of  autumn,  suffer  from  catarrh.  From 
the  extreme  susceptibility  of  these  two  great  mucous  surfaces  arise  a 
large  proportion  of  the  ailments,  and  many  even  of  the  serious  diseases 
of  infancy.  Morbid  as  well  as  reparative  processes  go  on  most  rapidly 
in  early  life  :  the  flux  of  to-day  may  to-morrow  be  attended  with  dysen- 
teric symptoms  ;  the  catarrh  of  to-day  may  to-morrow  have  put  on  the 
grave  features  of  acute  bronchitis. 

Now  these  two  circumstances  taken  together, — the  extreme  suscepti- 
bility of  the  respiratory  mucous  membrane,  and  the  rapidity  with  which 
its  trivial  disorder  sometimes  becomes  a  grave  disease, — give  to  the 
catarrhal  affections  of  infancy  an  importance  which  in  more  advanced 
life  they  do  not  possess.  This  importance,  too,  is  still  further  increased 
by  the  tendency  of  the  lung  to  become  collapsed  when  the  entrance  of 
air  into  its  minuter  cells  is  impeded  even  by  a  comparatively  trivial 
cause ;  while  in  other  cases,  or  even  in  connection  with  the  collapsed 
condition  of  the  lung,  the  inflammatory  process  may  invade  the  pul- 
monary cells  and  the  general  tissue  of  the  lung,  and  that  which  had 
seemed  a  slight  cold  may  grow  to  a  dangerous  bronchitis,  or  a  still  more 
dangerous  pneumonia. 

Of  catarrh  itself  and  its  general  characters  little  need  be  said. 
Allowing  for  the  difference  between  the  ages  of  the  patients,  its  symp- 
toms are  the  same  as  in  the  adult.  Sneezing  and  running  at  the  eyes 
and  nose,  and  cough,  a  hot  skin  and  quickened  pulse,  attend  it.  In 
some  children  the  febrile  disturbance  with  which  even  a  common  attack 
of  cold  sets  in  is  very  severe  for  the  first  twenty-four  hours  or  more,  and 
then  the  more  threatening  symptoms  subside,  and  the  true  nature  of 
the  affection  becomes  apparent.  At  other  times,  when  catarrh  is 
extremely  prevalent, — epidemic  in  short,  this  severe  onset  is  usual ;  and 
the  affection  closely  resembles,  or  is  probably  identical  with,  influenza. 
Often,  too,  you  will  find  the  commencement  of  an  epidemic  of  hooping- 
cough  preluded  by  an  unusual  prevalence  of  catarrh,  the  cough  by 
degrees  assuming  in  more  and  more  numerous  cases  the  paroxysmal 
character  and  peculiar  sound  of  pertussis.  It  is  unnecessary  to  allude 
to  the  catarrhal  symptoms  which  precede  measles  ;  but  bearing  in  mind 
that  what  seems  to  be  a  mere  cold  may  turn  out  to  be  the  first  stage  of 
a  very  serious  malady,  you  are  furnished  with  an  additional  reason  for 


TREATMENT  OF  CATARRH.   BRONCHITIS.  171 


not  slighting  it.  Lastly,  you  must  not  forget  that  the  frequent  return 
of  attacks  of  catarrh  is  sometimes  an  indication  of  that  irritable  state 
of  the  bronchial  membrane  which  the  abundant  deposit  of  tubercle  in  the 
lungs  occasions :  and  this,  again,  yields  another  argument  for  not 
neglecting  an  apparently  trivial  ailment. 

While  it  is  your  duty,  however,  on  so  many  grounds,  to  watch  closely 
every  child,  although  its  indisposition  may  not  seem  to  be  more  than  a 
simple  catarrh,  yet  in  the  way  of  actual  medical  treatment  very  little  is 
required.  The  child  must  be  kept  in  one  temperature ;  and,  if  the  nursery 
be  an  airy  room,  it  is  desirable  that  it  be  confined  to  that  apartment. 
If  already  weaned,  it  may  be  well  to  withdraw  some  of  the  more  solid 
articles  of  diet ;  if  not,  care  must  be  taken  that  the  child  does  not,  in 
consequence  of  its  thirst,  suck  too  much ;  and  a  little  barley-water 
should  therefore  be  given  it  from  time  to  time.  A  warm  bath  at  night 
will  do  much  to  allay  the  heat  of  skin ;  and,  if  the  febrile  disturbance  be 
considerable,  a  couple  of  grains  of  James's  powder,  with  half  a  grain  of 
calomel,  may  be  given  to  a  child  a  year  old,  at  bed-time.  During  the 
day,  a  mixture,  containing  a  few  drops  of  ipecacuanha  and  antimonial 
wine,  with  a  little  of  the  compound  tincture  of  camphor,  if  the  cough 
irritate  by  its  frequent  return,  may  be  given  with  advantage ;  and,  as 
the  fever  subsides,  the  spirits  of  nitrous  ether  may  be  substituted  for  the 
antimonial  wine.1 

(No.  9.)  (No.  10.) 

R  Vin.  Ipecacuanhae,  n^x.  R  "Vin.  Ipecac,  n^x. 

Vin.  Ant.  Pot.-Tart.  tt^xxx.  Oxym.  Scillae,  rr^xl. 

Tinct.  Camph.  co.  n^xx.  Spir.  iEth.  Nitr.  r^xx. 

Mist.  Amygdalae,  ^vij.  Tinct.  Camph.  co.  tt^xx. 

M.     gij.  4tis  horis.  Aquae  Anisi,  gviss. 

M.     gij.  4tis  horis. 
For  children  of  one  year  old. 

The  danger,  however,  in  these  cases,  is  of  a  more  grave  disorder  of 
the  air-passages  coming  on ;  and  this  brings  us  to  a  subject  which  we 
cannot  pass  over  hurriedly — namely,  the  bronchitis  and  penumonia  of 
infancy  and  childhood. 

The  study  of  these  affections  in  childhood  is  beset  by  some  difficulties 
which  we  do  not  meet  with  in  the  adult.  The  points  of  difference 
between  bronchitis  and  pneumonia  are  sufficiently  well  marked  in  the 
adult  for  all  purposes  of  practical  utility,  although  many  inquiries  may 
be  started  with  reference  to  the  intimate  nature  of  the  morbid  processes 
which  we  may  be  unable  to  answer  satisfactorily.  Besides,  whether  the 
capillaries,  or  the  pulmonary  cells,  or  their  parietes,  be  the  structures 
first  attacked,  it  is  clear  that  they  are  all  involved  in  pneumonia  from  a 
very  early  stage  of  the  disease ;  and  hence  we  find  it  attended  from  the 
outset  with  peculiar  symptoms,  such  as  do  not  occur  in  bronchitis. 
Pneumonia  similar  to  that  of  the  adult  is  sometimes  observed  even  in 
early  childhood ;  but  it  often  happens  that,  though  the  pulmonary  sub- 
stance becomes  eventually  a  partaker  in  the  disease,  it  yet  was  not  so  at 
first ;  but  the  inflammation,  beginning  in  the  larger  air-tubes,  has  passed 
along  them  to  the  smaller  bronchi,  and  then  at  length  involving  the 


172  MORBID  APPEARANCES  OF  THE  BRONCHI. 

tissue  of  the  lung,  the  case  comes  to  be  one  neither  of  pure  bronchitis 
nor  of  pure  pneumonia,  but  a  mixture  of  the  two,  which  has  not  inaptly 
been  termed  bronchio -pneumonia.  Another  source  of  difficulty  in  the 
study  of  these  affections,  as  well  as  an  occasion  of  the  great  peril  that 
attends  them,  is  the  tendency  which  we  have  already  observed  in  the 
lung  during  early  life  to  become  collapsed,  and  no  longer  to  admit  that 
air  without  which  the  changes  in  the  blood  cannot  take  place,  and  the 
absence  of  which  naturally  aggravates  the  mischief  that  the  inflammatory 
disease  itself  tends  so  immediately  to  produce. 

I  must  beg  you,  therefore,  to  pardon  me  if  I  enter  rather  more 
minutely  than  is  my  custom  into  the  description  of  the  morbid  appear- 
ances produced  by  inflammation  of  the  lungs  and  air-tubes  in  infancy 
and  childhood. 

An  increased  degree  of  redness  of  the  mucous  membrane  of  the  bronchi 
is  almost  constantly  observed  in  the  case  of  children  who  have  died  of 
inflammation  of  the  lungs  or  air-tubes.  There  are  three  sources  of 
error,  however,  against  which  it  is  essential  to  guard  when  examining 
the  bronchi  with  reference  to  this  point.  The  first  is  the  occasional 
disappearance  of  redness  after  death,  even  where  the  presence  of  an 
abundant  muco-purulent  secretion  in  the  tubes  bears  evidence  to  the 
activity  of  the  inflammatory  process ;  the  second  is  the  apparent  red- 
ness of  the  smaller  tubes  in  cases  where  the  lungs  are  congested  or 
inflamed,  and  which  may  be  due  not  to  the  increased  vascularity  of  the 
bronchi  themselves,  but  to  their  transparency,  allowing  that  of  the  sub- 
jacent tissue  to  be  seen  through  them.  The  third  is  the  ocasional 
staining  of  the  mucous  membrane,  owing  to  the  transudation  of  the 
blood  through  the  coats  of  the  vessels  after  death.  With  care,  however, 
none  of  these  circumstances  will  lead  you  astray. 

The  redness  of  the  bronchi  varies  much  both  in  degree  and  extent, 
and  in  some  cases  which  have  approached  to  the  character  of  pneumonia 
rather  than  of  bronchitis,  is  sometimes  limited  to  the  inflamed  lobes. 
In  cases,  however,  in  which  much  bronchitis  has  existed,  very  marked 
redness  generally  begins  about  an  inch  above  the  bifurcation  of  the 
trachea,  and  pervades  all  the  bronchi,  being  deeper  in  the  secondary 
than  in  the  primary  tubes,  and  retaining  nearly  as  great  an  intensity 
even  in  the  tertiary  branches.  It  may  stop  here,  or  it  may  extend 
even  into  the  ultimate  ramuscules,  or  into  the  pulmonary  cells  them- 
selves. 

In  the  majority  of  cases  no  other  change  besides  this  intense  redness 
is  perceptible  in  the  mucous  membrane,  but  sometimes  it  appears  both 
thickened  and  softened  ;  and  on  one  occasion  in  which  a  fatal  attack  of 
acute  bronchitis  supervened  on  a  long  continuance  of  the  chronic  stage 
of  the  disease,  the  bronchial  mucous  membrane  was  intensely  red,  and 
so  thickened  as  to  have  an  almost  villous  appearance,  and  closely  to 
resemble  red  velvet.  Ulceration  of  the  mucous  membrane  of  the 
trachea  and  larger  bronchi,  which  is  occasionally  met  with  in  the  bron- 
chitis of  adults,  I  never  observed  but  once.  In  that  case,  a  little  boy, 
twenty  months  old,  who  had  suffered  from  a  not  very  severe  attack  of 
bronchitis,  in  the  course  of  which,  however,  he  had  occasional  difficulty 
in  deglutition,  with  return  of  fluids  by  the  nose,  died  rather  suddenly. 


DILATATION   OF   THE  BRONCHI  173 

The  only  remarkable  appearance  besides  a  general  redness  of  the  bron- 
chial tubes  consisted  in  the  presence  of  several  small  excavated  ulcera- 
tions or  erosions  in  the  upper  part  of  the  larynx,  just  above  the  chordae 
vocales. 

Associated  with  the  changes  in  the  mucous  membrane  of  the  bronchi 
there  is  an  alteration  in  the  character  of  their  secretion.  At  first,  no 
doubt,  this  secretion  is  suppressed,  just  as  we  see  that  furnished  by  the 
Schneiderian  membrane  to  be  in  a  common  cold ;  but  afterwards  it  is 
poured  out  abundantly,  and  next  ceases  to  present  its  natural  characters 
of  a  glairy  mucus,  becoming  opaque,  thick,  puriform,  or  actually  puru- 
lent, while  in  a  few  less  common  instances  the  secretion  assumes  the 
form  and  consistence  of  false  membrane,  constituting  a  true  croup  of 
the  bronchi.  Any  traces  of  blood  are  but  very  seldom  observed  in  the 
secretion,  and  the  quantity  of  air-bubbles  intermingled  with  it  is  usually 
in  inverse  proportion  to  the  thickness  of  the  secretion  and  its  abundance. 

But  not  only  are  the  contents  of  the  air-tubes  altered  in  character, 
and  for  the  most  part  increased  in  quantity,  but  the  tubes  themselves 
often  undergo  a  marked  alteration  in  their  calibre,  and  become  greatly 
dilated.  This  dilatation  is  usually  observable  from  the  secondary 
bronchi  to  the  minutest  air-tubes ;  the  branches  often  being  as  large  as 
the  parent  trunk,  or  even  larger :  but  that  fusiform  dilatation  which  is 
met  with  in  the  adult  has  never  come  under  my  notice.  On  one  occa- 
sion, however,  in  addition  to  a  general  cylindrical  enlargement  of  the 
tubes  many  of  them  presented  a  marked  dilatation  about  half  an  inch 
from  their  termination  ;  the  tube  expanding  into  a  cavity  big  enough  to 
hold  half  a  nut.  The  interior  of  these  cavities  was  not  perfectly  smooth 
and  regular,  but  its  thickened  lining  was  in  many  parts  thrown  into 
folds  or  wrinkles.  The  case  in  which  this  appearance  was  observed  was 
the  one  already  mentioned,  where  the  mucous  membrane  of  the  bronchi 
presented  so  extraordinary  a  degree  of  thickening. 

Dilatation  of  the  bronchi  was  once  supposed  to  be  the  purely 
mechanical  effect  of  the  accumulation  of  the  secretions  within  them. 
There  is,  however,  no  constant  relation  between  the  quantity  of  the 
liquids  within  the  bronchi  and  the  degree  of  their  dilatation,  and  we 
must  look  to  two  other  circumstances  as  being  the  primary  causes  of 
the  occurrence.  The  first  of  these  is  the  weakening  of  the  muscular 
fibres  of  the  bronchi  by  the  inflammatory  action ;  the  other,  the  loss  of 
the  ciliary  epithelium  which  lines  the  air-tubes  when  in  a  state  of  health, 
and  contributes  by  the  incessant  vibration  of  its  cilia  to  keep  them  free 
for  the  access  of  air. 

Whenever  bronchitis  has  reached  such  an  intensity  as  to  give  rise  to 
the  abundant  pouring  out  of  thick  fluid  into  the  air-tubes,  so  that  the 
air  can  no  longer  permeate  them  with  facility,  while  this  difficulty  is 
still  further  increased  by  the  loss  of  the  ciliary  epithelium  and  by  the 
weakening  of  the  contractile  power  of  the  bronchi,  which  would  have 
helped  to  keep  them  free,  it  often  happens  that  the  feeble  inspiratory 
power  of  the  child  becomes  wholly  inadequate  to  fill  the  lungs;  large 
portions  of  them  collapse,  and  bronchitis  thus  becomes  the  indirect 
cause  of  carnification  of  the  lung. 

In  some  cases,  the  inflammation  of  the  respiratory  mucous  membrane 


174:  CONGESTION   OF   THE   LUNG. 

extends  further  than  usual  along  the  smaller  bronchi,  until  it  involves 
their  extremities  and  the  pulmonary  vesicles  themselves,  when  it  pro- 
duces an  appearance  almost  peculiar  to  childhood,  and  which  has  been 
described  under  the  names  of  vesicular  pneumonia  or  vesicular  bronchitis. 
A  lung,  or  a  portion  of  a  lung,  thus  affected,  no  longer  contains  any  air 
— it  is  dark  in  colour,  and  feels  tough,  though  solid  ;  its  surface  is  beset 
by  a  number  of  small,  circular,  yellow,  slightly  prominent  spots,  of  the 
size  of  a  millet-seed,  or  smaller,  which,  on  a  hasty  glance,  present  a  very 
great  resemblance  to  crude  tubercles.  A  very  little  attention,  however, 
suffices  to  distinguish  between  them  ;  for  not  only  do  these  yellow  spots 
differ  from  tubercle  in  their  favourite  seat  being  along  the  lower  margins 
of  the  different  lobes,  but  on  puncturing  any  of  them  with  the  point  of 
a  scalpel,  a  drop  of  pus  will  exude,  and  the  yellow  spot  will  disappear. 
Sometimes,  too,  a  minute  bronchus  may  be  traced  running  to  its  termi- 
nation in  one  of  these  little  sacs.  It  has  been  suggested  that  this 
appearance  may  be  due  to  the  secretions  formed  in  the  air-tubes  being 
forced  by  the  column  of  air  which  enters  in  inspiration  into  the  smaller 
bronchi  and  pulmonary  vesicles,  the  cavities  of  which  thus  become 
mechanically  distended.  The  opinion  that  the  secretions  which  occupy 
these  parts  are  produced  at  the  spot  where  they  are  discovered  by  inflam- 
mation of  the  ultimate  ramuscules  of  the  bronchi,  is,  however,  generally 
entertained,  and  is  supported  by  very  conclusive  evidence.  Bronchitis 
often  exists  unattended  with  this  peculiar  appearance ;  and  on  the 
other  hand,  vesicular  bronchitis  is  met  with  independent  of  general 
inflammation  of  the  air-tubes,  while,  though  usually  partial,  and  often 
limited  to  the  lower  border  of  one  or  other  lobe,  it  is  sometimes  very 
extensive,  and  occupies  nearly  the  whole  of  the  lower  lobe  on  either 
side,  constituting  the  most  important  of  the  morbid  appearances 
discovered  on  examining  the  chest. 

It  may,  and  unquestionably  often  does,  happen  that  children  die  of 
bronchitis  alone,  and  without  any  notable  affection  of  the  pulmonary 
tissue.  But  it  is  much  more  frequent  for  the  pulmonary  substance  to 
bear  a  part  in  the  morbid  process  ;  and  this  share  may  either  be  limited 
to  mere  congestion,  or  may  rise  in  degree  until  it  produces  all  those 
consequences  which  we  find  attendant  on  inflammation  of  the  tissue  of 
the  lung  in  the  adult. 

Some  degree  of  congestion  of  the  lung  is  almost  constant  if  bronchitis 
be  at  ail  severe,  for  the  circulation  through  the  organ  is  disturbed,  the 
blood  flows  less  freely  than  natural,  and  its  changes  take  place  more 
slowly.  It  stagnates  first  in  those  depending  parts  whence  position 
renders  its  return  most  difficult ;  and  the  portions  of  the  lung  thus 
affected  become  by  degrees  more  and  more  extensive.  Dark,  solid, 
non-crepitant  patches  may  be  often  seen  in  the  midst  of  a  lung  thus 
congested ;  and  until  the  results  of  inflation  shewed  that  a  wrong 
interpretation  had  been  given  of  the  appearance,  these  patches  were 
regarded  as  the  centres  whence  the  inflammation  was  extending  to  the 
surrounding  tissue.  You  do  not  need  to  be  reminded  that  they  are 
lobules  which  have  collapsed,  and  become  impervious  to  air ;  and 
portions  of  lung  in  which  this  occurrence  has  taken  place  seem  to  have 
but  little  disposition  to  become  the  seat  of  active  inflammation,  and  to 


TRUE   LOBULAR   PNEUMONIA.  175 

pass  into  a  state  of  red  or  grey  hepatization.  At  the  same  time,  how- 
ever, it  must  be  borne  in  mind  that  this  indisposition  to  active  inflam- 
mation does  not  by  any  means  amount  to  actual  immunity  from  it,  and 
that  carnified  lung  may  sometimes  become  softened,  or  even  infiltrated 
with  pus. 

It  does,  however,  happen  now  and  then  that  the  lung  is  found  in  a 
condition  which  may  justly  be  called  lobular  pneumonia,  as  the  result 
of  the  extension  to  the  surrounding  tissue  of  inflammation  beginning 
in  the  air-tubes.     Patches  of  lung  will  then  be  interspersed  through  the 
surrounding  pulmonary  tissue,  of  a  vivid  red  colour,  of  various  sizes, 
from  that  of  a  pea  to  that  of  an  almond,  irregular  in  shape,  and  not 
circumscribed  exactly  by  the  margins  of  lobules,  as  is  the  case  with 
portions  of  .carnified  lung.     This  process  going  on  in   a  number  of 
different  situations,  the  affected  parts  may  at  length   coalesce,  and  a 
pneumonia,  at  first  lobular,  may  thus  eventually  become  generalized. 
Or,  though  this  should  not  occur,  the  inflammation  may  yet  go-  on  in 
the  isolated  portions  of  lung  to  the  infiltration  of  pus  into  its  substance, 
or  the  actual  destruction  of  its  tissue,  when  a  portion  of  the  lung  will 
appear  riddled  with  small  distinct  abscesses,  seldom  larger  than  a  pea, 
irregular  in  form,  and    communicating  more  or  less  evidently  with  a 
minute    air-tube.       They  may   be    distinguished    from    the    vomicae 
produced   by  softened  tubercle,  partly  by  the  absence    of  tubercular 
deposits  in  other  parts  of  the  body,  and  by  their  being  almost  always 
limited  to  a  single  lobe  of  one  lung.     Their  own  characters,  however, 
are  sufficiently  well  marked,  for  they  are  altogether  destitute  of  those 
solid  walls   which  the   tubercular   deposit  forms   around   a  phthisical 
cavity ;  though    the  yellow  lymph  which  often  lines  them  may  be  mis- 
taken by  the  inattentive  observer  for  tubercle.  MM.  Rilliet  andBarthez 
mention  having  found  the  pulmonary  substance  healthy,  except  in  the 
immediate  periphery  of  these  abscesses  ;  but  no  instance  of  this  kind 
has  come  under  my  own  observation,  the   pneumonia  having  in  each 
instance  become  generalised. 

The  appearances  we  have  hitherto  been  considering  are  due  almost 
exclusively  to  inflammation  of  the  air-tubes ;  and  many  of  them  are 
peculiar  to  infancy  and  childhood.  We  might  next  proceed  to  study  the 
symptoms  that  betoken  their  existence;  but  on  the  one  hand,  they 
seldom  exist  quite  alone,  and,  on  the  other  hand,  their  symptoms  pre- 
sent so  many  points  of  resemblance  to  those  of  pneumonia  strictly  so 
called,  that  it  may  be  better  to  complete  our  survey  of  the  morbid 
appearances  that  result  from  inflammation  affecting  either  the  air-tubes 
or  the  parenchyma  of  the  lung,  before  we  pass  to  the  study  of  the 
symptoms  that  attend  the  one  or  the  other  during  life. 

The  completion  of  this  subject,  however,  must  be  postponed  to  the 
next  lecture. 


176  LOBULAR  PNEUMONIA — NOT   UNUSUAL   IN    CHILDHOOD. 


LECTURE  XVI. 

Inflammatory  Affections  of  the  Tissue  of  the  Lung — Lobar  Pneumonia — More 
common  in  early  life  than  has  been  supposed — Its  general  characters  the  same  as  in 
the  adult — Some  morbid  appearances  deserving  special  notice ;  viz.  sub-pleural 
ecchymoses,  pneumonic  abscess,  and  emphysema  of  the  uninflamed  portions  of  the 
lung. 

Frequency  and  causes  of  inflammation  of  the  respiratory  organs — Influence  of  age — of 
previous  attacks — of  various  diseases. 

Bronchitis — its  Symptoms  and  Treatment — A  more  serious  disease  than  in  the  adult, 
and  why — Symptoms  of  capillary  bronchitis — Illustrative  case — Results  jof  auscultation. 

Treatment  of  bronchitis — Rules  for  depletion  and  the  use  of  antimony — The  dyspnoea 
not  always  dependent  on  severity  of  the  inflammation — Treatment  of  this  nervous 
dyspnoea — Treatment  of  bronchitis  in  its  chronic  stage. 

'We  were  occupied  during  the  last  lecture  with  the  examination  of 
some  of  the  results  of  inflammation  of  the  respiratory  organs  in  early 
life,  and  considered  more  especially  those  changes  which  inflammation 
produces  in  the  air-tubes.  You  were  told  on  that  occasion  that  the 
disease  does  not  always  remain  limited  to  the  bronchi  or  pulmonary 
vesicles,  but  that  it  sometimes  involves  the  substance  of  the  lung,  and 
thus  gives  rise  to  the  appearance  of  a  number  of  small  circumscribed 
patches  interspersed  throughout  its  tissue,  either  red,  hard,  and  solid, 
or  grey  from  the  infiltration  of  pus;  while,  if  the  mischief  advance 
one  step  farther  it  may  lead  to  the  destruction  of  the  parenchyma  of 
the  organ  at  these  points,  and  thus  produce  numerous  minute  abscesses 
— a  condition  which  has  thrice  come  under  my  own  observation.  Cases 
of  this  kind,  constituting  true  lobular  pneumonia,  though  somewhat 
less  rare  than  in  the  adult,  are  yet  of  very  frequent  occurrence.  It  is 
almost  needless  to  remind  you  that  the  contrary  opinion  resulted  from 
persons  not  having  learned  till  very  lately  to  distinguish  between  that 
solidity  of  the  lung  which  is  produced  by  inflammation,  and  that  which 
results  from  the  mere  collapse  of  its  air-cells. 

The  exaggerated  estimate  of  the  frequency  of  lobular  pneumonia,  and 
the  peculiar  character  of  the  field  presented  at  the  Hospital  for  Children 
at  Paris,  in  which  the  most  diligent  and  most  successful  students  of 
children's  disease  laboured,  led  to  an  underrating  of  the  frequency  and 
importance  of  lobular  pneumonia  such  as  is  met  with  in  the  adult ;  and 
hence  you  will  find  but  little  said  concerning  it  in  many  of  the  most 
valuable  works  of  our  continental  neighbours.  Lobar  pneumonia, 
however,  is  often  met  with  in  early  life,  both  as  an  idiopathic  and  a  second- 
ary affection,  giving  rise  to  the  same  morbid  appearances  as  in  the  adult 
and  requiring  a  very  similar  treatment. 

Not  only  are  the  physical  characters  of  the  lung  in  lobar  pneumonia 
the  same  in  childhood  as  in  adult  age,  but  the  three  stages  of  engorge- 
ment, of  red  and  of  grey  hepatization,  are  observed  with  much  the  same 
frequency  at  the  one  period  of  life  as  at  the  other.  I  find  that  after 
rejecting  all  cases  in  which  pneumonia  occurred  as  a  complication  of 
phthisis,  or  of  acute  pleurisy,  and  in  which  the  results  might  be  modified 


LOBAR  PNEUMONIA — NOT   UNUSUAL   IN   CHILDHOOD.  177 

by  the  disease  to  which  the  inflammation  of  the  lung  succeeded,  I  have 
a  record  of  47  cases  in  which  the  condition  of  the  inflamed  lung  was 
carefully  noticed. 

In    5  of  these  cases  the  1st  and  2d  stages  of  pneumonia  co-existed. 

"     4  "  "  1st  and  3d  "  " 

"  13  "  "  2d  and  3d  " 

"  11  "  "  all  3  stages 

M     3  "  w  lung  was  in  the  1st  stage  only. 

"     6  "  "  lung  was  in  the  2d         " 

"     5  "  "  lung  was  in  the  3d         " 


u  a 


47 

This  result  tallies  very  closely  with  that  obtained  by  M.  Grisolle,1  on 
an  examination  of  40  cases  of  pneumonia  in  the  adult. 

In    4  cases  the  1st  and  2d  stages  of  pneumonia  co-existed. ' 
"     3         "        1st  and  3d  "  " 

"  16        "        2d  and  3d  "  " 

"     2        "        all  3  stages  "  " 

*     7         M        lung  was  in  the  2d  stage  only. 
"     8         "        lung  was  in  the  3d         "  . 

40 

It  will  be  seen,  on  a  comparison  of  these  tables,  that  the  third  stage 
of  pneumonia  occurs  very  nearly  as  often  in  children  as  in  adults, 
having  been  met  with  in  the  former  in  theproportion  of68,  in  the  latter 
in  the  proportion  of  72  per  cent. ;  and  the  main  difference  between  the 
two  consists  in  the  greater  frequency  with  which  all  three  stages  of 
pneumonia  co-exist  in  the  young  subject.  This  peculiarity  of  pneu- 
monia in  childhood  is  probably  due  to  the  tendency  which  the  disease 
then  displays  to  involve  a  large  extent  of  pulmonary  tissue ;  and  to  the 
same  cause  we  must  attribute  the  frequency  of  double  pneumonia  in 
early  life,  which,  in  the  cases  that  came  under  my  notice,  preponderated 
greatly  over  those  wherein  only  one  lung  suffered.  The  well-known 
law,  according  to  which  pneumonia  of  the  right  lung  is  more  common 
than  pneumonia  of  the  left,  holds  good  in  childhood  ;  nor  is  the 
frequency  of  the  concomitant  pleurisy,  much,  if  ,at  all,  less  in  the  child 
than  in  the  adult.  The  contrary  opinion  arose  from  the  error  to  which 
reference  has  so  often  been  made,  of  regarding  cases  of  collapsed  lung, 
either  with  or  without  bronchitis,  as  instances  of  red  hepatization 
of  the  pulmonary  substance. 

Instead  of  inflammation  of  the  lungs  being  less  active  in  the  child 
than  in  the  adult,  there  are  some  facts  which  would  seem  to  lead  to  a 
directly  opposite  conclusion.  Such  are  the  frequency  with  which,  in 
fatal  pneumonia  in  children,  ecchymoses  are  found  beneath  the  pleura 
covering  the  inflamed  lung,  the  more  common  occurrence  of  pulmonary 
abscess  in  early  than  in  adult  life,  and  the  very  extensive  emphysema 

1  Traitd  de  la  Pneumonie,  8vo.  Paris,  1841,  p.  18. 
12 


178  PULMONARY  ABSCESS. 

which  is  often  observed  in  those  parts  of  the  lung  to  which  the  inflam- 
mation has  not  extended. 

These  sub-pleural  ecchymoses  appear  to  result  from  the  rupture  of 
some  of  the  minute  capillaries  of  the  lungs  in  consequence  of  the  great 
disturbance  of  the  circulation  through  them.  They  are  usually  small, 
like  petechia,  but  occasionally  they  attain  a  larger  size,  and  once  or 
twice  they  have  presented  themselves  to  me  extending  a  little  way  into 
the  tissue  of  the  lung,  constituting  little  spots  of  pulmonary  apoplexy, 
about  the  size  of  a  millet-seed,  or  even  a  little  larger.  They  are  most 
numerous  on  the  posterior  surface  of  the  lungs,  and  especially  in  parts 
where  the  lung  has  become  hepatized,  though  by  no  means  confined  to 
those  situations. 

The  termination  of  pneumonia  in  abscess  of  the  lung  is  so  rare  an 
occurrence  in  the  adult,  that  Laennec  did  not  meet  with  it  above  five  or 
six  times  in  the  course  of  several  hundred  examinations  of  persons  who 
had  died  of  inflammation  of  the  lungs.  In  the  child,  however,  the  case 
is  otherwise,  for  abscess  of  the  lung  has  come  under  my  observation  in 
three  out  of  the  forty-seven  examinations  of  cases  of  lobar  pneumonia, 
on  which  my  present  remarks  are  founded.  In  one  of  these  cases,  that 
of  a  boy,  aged  20  months,  who  died  on  the  fourteenth  day  after  the 
commencement  of  an  illness  which  resembled  remittent  fever  in  many 
of  its  symptoms,  but  was  associated  from  the  outset  with  the  indications 
of  pneumonia,  the  following  appearances  we're  observed : — The  upper 
and  middle  lobes  of  the  right  lurtg  were  connected  to  each  other,  and  to 
the  walls  of  the  chest,  by  adhesions  which  were  chiefly  recent.  Nearly 
the  whole  of  the  upper  lobe  was  solid,  and  sank  in  water.  It  was  of  a 
mottled  reddish  grey  colour,  in  which  grey  predominated ;  it  broke  with 
a  granular  fracture,  and  was  readily  reduced  to  a  dirty  putrilage.  Near 
the  apex  was  a  portion  the  size  of  a  walnut,  which  was  already  soft  and 
in  a  state  of  quagmire.  The  upper  two-thirds  of  the  middle  lobe  were 
in  the  same  condition  as  the  upper  lobe ;  the  lower  third  was  emphy- 
sematous. In  the  centre  of  the  middle  lobe  was  a  cavity  the  size  of  a 
bean,  irregular  in  form,  intersected  by  the  remains  of  some  vessels, 
lined  by  a  thin  layer  of  yellow  lymph,  and  surrounded  by  lung  in  the 
third  stage  of  pneumonia ;  but  neither  in  that  lobe  nor  in  any  part  of 
the  pulmonary  tissue  was  there  the  least  trace  of  tubercle,  and  the  only 
indication  of  phthisical  disease  consisted  in  one  bronchial  gland  having 
become  converted  into  tubercle  which  had  undergone  the  cretaceous 
transformation.  The  lower  lobe  of  the  right  lung  was  in  the  first  stage 
of  pneumonia ;  the  left  upper  lobe  was  quite  healthy ;  the  left  lower 
lobe  was  in  a  state  of  mingled  red  and  grey  hepatization.  The  other 
two  cases  occurred  in  children  who  had  suffered  for  some  weeks  from 
hooping-cough,  and  in  both  the  lungs  contained  numerous  semi-trans- 
parent, grey,  tubercular  granulations.  One  of  the  children  was  a  boy, 
five  years  old  ;  the  other  a  little  girl,  aged  two  years.  In  the  case  of 
the  former,  the  abscess,  as  large  as  a  walnut,  was  situated  at  the  lower 
border  of  the  upper  lobe,  extending  a  little  into  the  lower  lobe.  In  the 
latter  it  was  of  the  size  of  an  unshelled  almond,  and  occupied  a  simi- 
lar position  with  reference  to  the  right  upper  and  middle  lobes.  The 
characters  of  the  abscess  were  the  same  in  both  instances,  being  situated 


CAUSES   OF   PNEUMONIA.  179 

almost  immediately  beneath  the  pleura;  from  which  a  wall  of  lung  not 
above  two  lines  in  thickness  separated  it.  Its  cavity  was  partly  filled 
with  a  yellowish,  puriform,  very  tenacious  fluid,  like  very  tenacious  pus, 
and  which  did  not  bear  any  resemblance  to  softened  tubercle.  It  was 
not  lined  by  any  membrane :  there  was  no  appearance  of  tubercular 
deposit  in  the  hepatized  lung  in  its  immediate  vicinity,  which  was  gene- 
rally in  the  second  stage  of  pneumonia,  nor  was  it  situated  near  to,  nor 
in  communication  with  any  large  bronchial  tube. 

The  lung  in  childhood  shows  a  much  greater  tendency  to  pass  into  a 
state  of  gangrene,  than  in  adult  age.  It  may  be  doubted,  however, 
whether  this  gangrene  is  the  result  of  the  intensity  of  the  inflammation 
so  much  as  of  some  peculiar  change  of  blood  which  favours  the  occur- 
rence of  mortification.  The  occasional  prevalence  of  gangrene  of  the 
lung  and  of  other  parts,  as  an  endemic  affection,  in  the  Hopital  des 
Enfans  at  Paris,  favours  the  latter  supposition,  and  the  only  instance 
of  it  that  has  come  under  my  own  observation  in  the  child  is  quite  in 
accordance  with  it. 

The  emphysematous  condition  of  the  uninflamed  portions  of  the  lung, 
in  cases  of  fatal  pneumonia  in  early  life,  seems  to  be  connected  with 
the  rapidity  of  the  advance  of  the  disease.  It  is  usually  most  obvious 
at  the  anterior  part  of  the  upper  lobes  of  the  lungs,  and  at  the  margin  of 
the  other  lobes,  and  always  bears  a  marked  relation  to  the  shortness  of 
the  patient's  illness,  and  the  extent  of  lung  which  has  been  invaded  by 
the  inflammation.  The  delicate  structure  of  the  lung  in  early  life 
seems  to  be  the  cause  why  the  pulmonary  vesicles  so  easily  become 
dilated  during  the  hurried  inspiratory  efforts,  by  which  the  child  endea- 
vours to  make  up  for  the  derangement  of  a  part  of  that  machinery  by  which 
the  vital  changes  in  the  blood  are  effected.  It  is  probably,  as  suggested 
by  MM.  Rilliet  and  Barthez,  to  its  production  in  this  way,  that  may  be 
referred  the  origin  of  many  of  those  cases  of  emphysema  which  we  meet 
with  in  the  adult,  but  which  date  back  from  early  childhood. 

The  causes  which  give  rise  to  inflammation  of  the  lungs  and  air-tube? 
are,  to  a  great  extent,  the  same  at  all  periods  of  life  ;  so  that  we  need 
not  devote  much  attention  to  the  special  study  of  those  which  tend  to 
produce  it  in  childhood.  It  should  be  borne  in  mind,  however,  that  the 
fluctuations  in  temperature,  or  the  biting  wind,  or  the  cold  weather, 
which  may  be  encountered  with  impunity  by  the  robust  adult,  may 
prove  most  deadly  when  they  act  on  the  feeble  frame  and  delicate  or- 
gans of  the  child.  Hence  it  is,  in  great  measure,  that  inflammation  of 
the  respiratory  organs  is  so  much  more  frequent,  and  so  much  more 
fatal,  in  childhood  than  in  adult  age,  and  in  infancy  than  in  childhood. 
The  fact  is  well  shown  by  the  Reports  of  the  Registrar-General  for  the 
years  1842  and  1845,  from  which  it  appears  that  67-1  per  cent,  of  the 
total  mortality  from  inflammation  of  the  lungs  and  bronchi,  in  the 
metropolis,  took  place  in  persons  under  fifteen  years  of  age ;  63.2  per 
cent,  under  five  ;  57.1  under  three ;  and  28.7  per  cent,  under  one  year. 
But  the  tendency  to  these  affections,  as  is  shown  in  the  following  table, 
is  not  greatest  in  the  first  month  of  life,  diminishing  in  proportion  as 
the  child  advances  in  age  and  increases  in  strength  ;  but  the  time  when 
they  are  most  prevalent  coincides  exactly  with  the  time  when  the  sus- 


180 


CAUSES   OF  PNEUMONIA. 


ceptibility  of  all  the  mucous  membranes  is  at  its  highest  point,  namely, 
the  period  of  dentition. 


Table,  showing  out  of  183  cases  of  children  dying  from  various 
diseases,  in  whom  I  carefully  examined  the  thoracic  viscera,  the 
number  of  instances  in  which  the  lungs,  bronchi,  and  'pleura,  pre- 
sented no  signs  of  recent  inflammation,  and  also  those  in  which 
signs  of  it  were  discovered.  [The  first  line  represents  the  former, 
the  second  the  latter  class  of  cases.] 


Under 

From  From 

From 

From 

From 

From 

From 

From 

From 

From  From 

From 

From 

From 

Total. 

1  m'th. 

1-6.  1  6-12. 

12-18. 

18-2. 
yrs. 

2-3. 

3-4. 

4-5. 

5-6. 

6-7. 

7-8. 

8-9. 

9-10. 

10-11. 

11-12. 

5 

13 

17 

13 

5 

11 

9 

5 

6 

3 

2 

2 

2 

93 

3 

10 

13 

15 

12 

10 

8 

5 

3 

5 

2 

2 

2 

90 

This  table  illustrates  the  fact  mentioned  in  the  last  lecture,  that, 
when  the  child  is  first  born,  the  mucous  membrane  of  the  respiratory 
organs  is  endowed  with  but  little  of  that  susceptibility  which  it  after- 
wards acquires,  and  that  accordingly,  those  diseases  whose  point  of 
departure  is  from  that  membrane,  are  far  less  frequent  during  the  first 
six  months  of  life,  than  they  become  during  the  succeeding  eighteen 
months  ;  while,  from  the  completion  of  the  second  year  up  to  the  time 
of  puberty,  they  go  on  diminishing  in  frequency  and  fatality.  And 
there  are  important  practical  inferences  which  may  be  deduced  from 
the  facts  we  have  just  mentioned.  They  teach  us  not  only  that  a 
catarrh  is  a  much  more  serious  thing  in  infancy  than  in  adult  age,  but 
also  that  it  is  more  serious  at  one  period  of  infancy  than  at  another, 
and  they  warn  us  to  guard  a  child,  during  the  time  that  the  process  of 
teething  is  going  on,  with  double  care  against  all  causes  that  are  likely 
to  excite  inflammation  of  its  respiratory  organs. 

There  are  some  diseases  which,  after  having  occurred  once,  confer 
on  persons  an  immunity  from  subsequent  attacks.  This,  however,  is 
far  from  being  the  case  with  bronchitis  or  pneumonia  in  early  life,  but 
the  susceptibility  of  the  respiratory  organs  appears  to  increase  in  exact 
proportion  to  the  frequency  with  which  they  have  already  suffered,1  and 
a  child  who  has  once  been  attacked  by  inflammation  of  the  lungs  or 
air-tubes,  is  more  likely  to  have  a  second  attack  brought  on  by  a  slight 
change  of  temperature,  than  another  who  had  never  suffered  from  it 
would  be  to  experience  a  seizure  from  a  much  graver  cause.  With 
advancing  age,  this  susceptibility  seems  to  wear  out, — the  child  out- 
grows it ;  but  we   should  act  most  unwisely  if  we  were  to  sanction 

1  In  a  tract  on  Pneumonia  in  Children,  published  some  years  ago  in  the  British  and 
Foreign  Medical  Review,  I  mentioned  that  of  78  children  who  came  under  my  care  for 
inflammation  of  the  lungs,  31  were  stated  to  have  had  previous  attacks  of  the  disease  ; 
21  once  ;  4  twice ;  2  four  times  ;  and  4  were  said  to  have  had  it  several  times,  though 
the  exact  number  of  seizures  was  not  mentioned.  Of  these  31,  10  were  under  two  years 
of  age,  10  between  two  and  three,  and  the  remaining  11  between  three  and  six. 


DISEASES   PREDISPOSING   TO   PNEUMONIA. 


181 


exposure  to  the  cold,  with  the  view  of  hardening  a  child  against  its 
influence. 

The  importance  of  inflammatory  diseases  of  the  respiratory  organs, 
depends  not  merely  on  the  frequency  of  their  occurrence  as  idiopathic 
affections,  but  also  on  their  tendency  to  supervene  in  the  course  of 
other  maladies.  This  tendency,  though  very  evident  at  all  ages,  is 
especially  remarkable  in  early  life,  as  is  apparent  from  the  fact  that, 
in  26  only  of  the  90  cases  enumerated  in  the  former  table,  was  the 
inflammation  an  idiopathic  affection.  When  we  come  to  the  subject  of 
measles,  hooping-cough,  croup,  diarrhoea,  and  remittent  fever,  it  will 
be  necessary  to  study  these  secondary  attacks  of  bronchitis  and  pneu- 
monia with  attention,  since  they  constitute  frequent  and  serious  com- 
plications of  those  diseases,  against  which  it  behoves  us  to  be  most 
anxiously  on  the  watch. 

Before  we  pass  to  the  examination  of  the  symptoms  of  bronchitis  and 
pneumonia,  it  may  be  as  well  to  see  whether  any  light  can  be  thrown, 
from  the  table  we  have  more  than  once  referred  to,  on  the  question  of 
what  diseases  predispose  to  inflammation  of  the  respiratory  organs. 
The  number  of  observations  on  which  it  is  based  is  too  small  to  warrant 
any  very  positive  conclusions,  but  some  of  the  results  which  it  yields 
are  not  without  interest. 

In  77  cases  the  respiratory  organs  presented  no  sign  of  recent  inflam- 
mation ;  the  children  having  died  of  the  following  diseases : — 

Trismus 3 

Meningeal  apoplexy 2 

Cerebral  congestion     ......  3 

Inflammation  of  the  brain    .....  2 

Acute  hydrocephalus 29 

Cerebro-spinal  arachnitis     .....  3 

Chronic  hydrocephalus 1 

Tubercle  of  the  brain 7 

Cancer  of  the  brain    ......  1 

Croup         .         .         .         .         ...         .         .  2 

Malformed  Heart,  pericarditis     ....  1 

Laryngismus  stridulus         .....  2 

Phthisis 5 

Anasarca   ........  1 

Anasarca  after  scarlet  fever         ....  1 

Diarrhoea  .         .         .         .         .         .         .         .  4 

Atrophy 3 

Congenital  syphilis     ......  1 

Cancrum  oris 2 

Lumbar  abscess 1 

Scrofulous  disease  of  the  vertebrae        ...  1 

Fungus  hsematodes  of  the  liver     ....  1 

"           "            "        kidney          .         .  I 

In  16  other  cases,  though  there  was  no  sign  of  inflammation,  yet  a 
more  or  less  considerable  portion  of  the  lung  was  collapsed,  but  restored 
by  inflation  to  its  natural  condition,  or  presented  the  physical  characters 


182 


DISEASES   PREDISPOSING   TO  PNEUMONIA. 


of  collapsed  lung  in  so  marked  a  degree  as  to  preclude  the  possibility 
of  error. 


The  cause  of  death  in  these  16  cases  was — 
Congenital  atelektasis  .... 

Induration  of  the  cellular  tissue  ... 
Convulsions        ...... 

Trismus 

Meningitis  of  the  convexity  of  the  brain 
Congestion  of  the  brain  occurring  in  the  course  of 
hooping-cough      ..... 

Tubercle  of  the  brain 

Atrophy  of  one  hemisphere  of  the  cerebellum 

Atrophy 

Laryngismus  stridulus  ...         * 

Fungus  hasmatodes  of  the  kidney 

Anasarca  after  scarlet  fever,  with  serous  effusion 

into  the  pleurae 


In  52  of  the  above  93  cases,  the  pulmonary  tissue  was  quite  free 
from  tubercle. 

In  80  the  lungs  contained  crude  tubercle  only ;  chiefly,  but  not 
entirely,  in  an  early  stage. 

In  4,  some  softened  tubercles. 

In  7,  some  tubercular  cavities. 

In  the  remaining  90  cases,  either  the  pulmonary  substance,  the 
bronchi,  or  the  pleura,  showed  signs  of  recent  inflammation. 

The  pleura  was  mainly  affected  in  twelve  of  these  cases,  its  inflam- 
mation having  been  idiopathic  only  in  4.  In  6  of  these  cases  the  lung 
was  inflamed ;  in  the  other  6  merely  compressed. 

In  21  cases  the  inflammation  was  chiefly  or  entirely  confined  to  the 
bronchi,  and  in  6  of  these  the  inflammation  was  idiopathic. 

In  57  cases  pneumonia  prevailed,  which  was  idiopathic  in  17,  and 
secondary  in  46  instances. ' 

In  the  61  cases  of  acute  secondary  inflammation  of  the  lungs  or 
bronchi,  the  patients  had  suffered  from  the  following  diseases : — 


Acute  pleurisy   . 

.         .         • 

6 

Hooping-cough   . 

.         .         • 

16 

Chronic  bronchitis 

... 

1 

Coryza       .... 

.         .         •         < 

1 

Croup         .         .         . 

• 

5 

"        consequent  on  measles 

.         .         • 

2 

Measles      .         . 

.         .         .         « 

5 

Scarlatina 

... 

3 

Anasarca  after  scarlatina    . 

... 

1 

Remittent  fever . 

... 

2 

Cancrum  oris  after  remittent  fever 

1 

Diarrhoea  . 

... 

3 

Acute  rheumatism 

... 

1 

SYMPTOMS   OF   BRONCHITIS. 


18 


Dilatation  of  the  heart 

•         « 

1 

Phthisis 

.         , 

7 

Convulsions 

.         , 

1 

Acute  meningitis 

,         . 

2 

Acute  hydrocephalus  . 

• 

3 

Of  the  whole  90  cases — 

In  72  the  pulmonary  tissue  was  free  from  tubercle. 
"  10  it  contained  tubercle  unsoftened. 
"    5  "  "  softened. 

"    3  "        tubercular  cavities. 


"We  will  now  pass  to  the  study  of  the  symptoms  of  bronchitis,  and 
will  commence  with  the  examination  of  the  most  simple  form  of  inflam- 
mation of  the  air-tubes, — namely,  that  which  develops  itself  out  of  ordi- 
nary catarrh.  In  such  a  case,  the  child  has  for  some  days  seemed  to 
suffer  from  nothing  more  serious  than  a  common  cold ;  but,  by  degrees, 
instead  of  the  cold  and  cough  subsiding,  the  heat  of  skin  becomes 
more  considerable,  the  cough  tighter,  more  frequent,  and  more  painful, 
the  child  sometimes  crying  after  each  cough :  the  pulse  becomes  more 
rapid,  the  respiration  wheezing,  hurried,  and  often  somewhat  irregular. 
These  graver  symptoms  often  steal  on  very  gradually,  and  among  the 
poor  it  by  no  means  seldom  happens  that  the  disease  has  already 
attained  an  advanced  stage,  and  the  condition  has  become  one  of  very 
considerable  peril,  before  the  parents,  never  very  observant  of  those 
ailments  that  are  not  attended  with  acute  suffering,  take  the  alarm. 
The  flush  of  the  face,  and  the  heat  of  skin  become  increased,  the  res- 
piration grows  more  laboured,  and  the  cough  more  troublesome  towards 
evening  ;  and  the  first  hours  of  the  night  are  usually  very  restless,  but 
the  child  then  falls  asleep,  and  often  dozes  tranquilly  for  some  hours ; 
it  then  generally  awakes  with  its  respiration  very  oppressed,  for  the 
secretions  have  been  accumulating  in  the  smaller  bronchi,  and  have  now 
begun  to  impede  the  entrance  of  the  air.  An  attack  of  cough  probably 
comes  on,  which  very  likely  ends  in  vomiting  and  the  rejection  of  some 
mucus,  and  then  by  degrees  the  breathing  becomes  more  easy,  and  the 
child  may  for  a  short  time  seem  comparatively  cheerful.  The  tempera- 
ture of  the  surface,  though  increased,  is' variable;  and,  if  the  disease 
continue  for  several  days,  perspiration  will  be  observed  occasionally 
to  break  out  on  the  body,  while  the  pulse,  though  quickened,  is  not 
very  much  accelerated,  and  the  tongue  continues  moist  throughout. 
The  ear  detects  nothing  in  the  chest  besides  a  mixture  of  rhonchus, 
sibilus,  and  largish  crepitation  ;  the  dry  sounds  preponderating  at  the 
upper,  the  moist  at  the  lower  part  of  the  chest,  and  being  vastly  more 
abundant  behind  than  in  front.  Now  in  the  adult,  a  condition  such  as 
this,  would  excite  but  little  apprehension,  but  in  the  child  it  must  be  borne 
in  mind  that  nothing  more  is  needed  than  a  copious  secretion  of  mucus 
in  the  bronchi,  or  a  feeble  condition  of  the  vital  powers,  to  prevent  the 
air  from  freely  entering  the  pulmonary  vesicles,  and  thus  to  induce  the 
collapse  of  a  large  portion  of  the  lung.     Thus  it  is,  at  least  as  I  appre- 


134  SYMPTOMS   OF   CAPILLARY   BRONCHITIS. 

hend,  that  we  must  explain  many  of  the  instances  in  which  urgent 
dyspnoea,  and  all  the  symptoms  of  serious  pulmonary  disease  have 
developed  themselves  in  the  course  of  a  few  hours  out  of  what  had 
seemed  to  be  nothing  more  than  a  rather  severe  cold,  or  a  bronchitis  of 
moderate  intensity.  This,  too,  accounts  for  the  occasional  sudden 
supervention  of  dulness  on  percussion,  and  of  bronchial  respiration  in 
the  child ;  so  that  you  may  discover  them  in  the  morning  in  a  situation 
where  over  night  the  percussion  was  good,  and  no  sound  was  heard  of 
graver  import  than  large  crepitation ;  changes  which,  unlike  those 
dependent  on  solidification  of  the  lung  from  inflammation,  you  may 
find,  as  has  been  remarked  by  Dr.  Gairdner,  of  Edinburgh,  unaccom- 
panied by  any  exacerbation  of  the  febrile  symptoms.  This  rapid 
change  in  the  auscultatory  phenomena,  has  been  noticed  by  Dr.  Stokes 
as  occasionally  happening  in  the  pneumonia  of  the  adult.1  That  dis- 
tinguished physician  offered  no  explanation  of  the  occurrence ;  but  we 
can  now  understand  what  is  its  true  import,  and  what  the  reasons  are 
for  its  being  met  with  so  much  oftener  in  the  child  than  in  the  adult. 

But,  notwithstanding  this  danger,  which  is  great  in  proportion  to  the 
youth  of  a  child,  yet  most  cases  of  idiopathic  bronchitis  that  come  on 
gradually,  developing  themselves  out  of  previous  catarrhal  symptoms, 
have  a  favourable  termination  ;  and,  as  a  general  rule,  it  may  be 
stated  that  an  attack  which  is  long  in  arriving  at  its  acme  is  seldom 
very  dangerous  in  its  character.  Pure  idiopathic  bronchitis,  occurring  * 
in  an  otherwise  healthy  child,  in  most  cases  subsides  in  the  course  of  a 
few  days,  leaving  the  patient  with  an  increased  susceptibility  to  the 
influence  of  those  causes  which  brought  on  the  first  attack,  and  perhaps 
with  a  degree  of  debility,  the  recovery  from  which  may  be  protracted 
for  many  weeks. 

There  is,  however,  a  form  of  acute  bronchitis  which  is  often,  though 
not  always,  idiopathic,  that  runs  its  course  with  much  rapidity,  and 
generally  tends  to  a  fatal  termination.  In  this,  the  suffocative  catarrh 
of  some  writers, — the  capillary  bronchitis  of  others, — the  smaller  air- 
tubes  throughout  the  whole  or  a  considerable  portion  of  the  lungs  are 
attacked  either  in  connection  with  the  larger  bronchi  or  independently 
of  them  ;  and  the  inflammation,  which  is  very  intense,  usually  termi- 
nates in  the  abundant  secretion  of  pus,  or  in  the  formation  of  false 
membrane  that  nearly  obliterates  their  cavity,  or,  involving  the  pulmo- 
nary vesicles  themselves,  it  gives  rise  through  a  considerable  extent  of 
the  lungs  to  those  appearances  which  have  been  described  under  the 
names  of  vesicular  pneumonia  and  vesicular  bronchitis. 

Its  attack  is  sometimes  sudden,  though  in  the  great  majority  of  cases 

it  is  preceded  for  a  few  days  by  the  ordinary  symptoms  of  catarrh,  or  it 

supervenes  on  that  condition  of  bronchial  irritation  whieh  accompanies 

or  follows  one   or  other  of  the  eruptive  fevers.     Under  these  latter 

circumstances  there  is  either  a  progressive  though  rapid  increase  in  the 

severity  of  the  bronchitic  symptoms,  or  there  is  a  sudden  outbreak  of 

fever  and  dyspnoea,  and  the  cough  becomes  all  at  once  frequent,  short, 

and  hacking.     The  disease  soon  attains  a  very  considerable  intensity ; 

i 

1  On  the  Diseases  of  the  chest.     8vo.  Dublin,  1837,  pp.  311  and  327. 


SYMPTOMS   OF   CAPILLARY   BRONCHITIS —  185 

the  face  becomes  anxious  and  oppressed,  the  eyes  heavy,  the  manner 
distressed ;  the  respiration  very  hurried,  generally  irregular,  and  inter- 
rupted by  the  cough,  which  frequently  seems  to  occasion  pain.  The 
restlessness  is  often  extreme,  and  the  position  which  the  child  assumes 
very  variable  ;  'but,  in  whatever  attitude  it  may  have  placed  itself,  it 
does  not  like  to  be  disturbed,  and  endeavours  at  once  to  return  to  its 
former  posture.  If  spoken  to,  the  child's  answers  are  hurried,  and  its 
manner  impatient,  as  though  it  were  too  much  taken  up  with  its  suffer- 
ing, or  with  the  business  of  respiration,  to  be  able  to  reply  to  questions. 
Sometimes  it  will  say  that  it  feels  stuffed,  or  will  complain  of  distress 
about  the  sternum,  or  of  pain  at  the  epigastrium;  while  pressure  on 
the  abdomen,  by  interfering  with  the  free  descent  of  the  diaphragm, 
always  produces  much  discomfort.  There  is  no  appetite ;  and,  though 
at  first  the  thirst  is  very  considerable,  yet  the  child  soon  ceases  to  take 
much  drink,  for  it  wants  breath  to  swallow  fluids  in  any  quantity,  and 
therefore  does  little  more  than  moisten  its  lips.  At  the  same  time  the 
tongue  is  moist,  and  either  differs  but  little  from  its  condition  in  health, 
or  it  has  a  thin  coating  of  yellowish  fur  ;  the  bowels  are  usually  con- 
stipated, and  not  only  are  nausea  or  vomiting  seldom  present,  but 
emetic  remedies  often  fail  of  their  ordinary  effect  when  given  in  the 
course  of  this  affection.  As  the  disease  advances  the  cough  becomes 
less  hacking,  though  it  continues  very  frequent :  it  sometimes  puts  on 
a  paroxysmal  character,  and  returns  in  fits  somewhat  like  those  of 
hooping-cough,  except  that  each  fit  of  coughing  is  shorter,  does  not 
terminate  with  a  whoop,  and  is  seldom  attended  with  expectoration. 
Even  if  the  cough  be  accompanied  by  expectoration,  it  is  seldom  that 
any  thing  is  spit  up  more  than  a  little  mucus  tinged  with  blood,  or  now 
and  then  a  little  pure  blood,  while  in  a  few  instances  small  shreds  of 
false  membrane  have  been  seen  intermingled  with  the  mucus.  For  a 
time  the  respiration  grows  more  and  more  hurried,  and  paroxysms  of 
dyspnoea  continue  to  occur  at  irregular  intervals  almost  to  the  last. 
In  these  paroxysms  the  child's  distress  and  restlessness  are  extreme, 
and  it  sometimes  throws  itself  wildly  about  the  bed.  The  breathing 
does  not,  however,  go  on  increasing  in  rapidity  until  the  patient's 
death;  but,  after  the  disease  has  reached  its  acme,  the  respiration  often 
grows  less  frequent,  though  more  irregular  and  more  variable.  The 
face  loses  its  flush,  and,  instead,  acquires  a  livid  hue  ;  the  cough 
becomes  smothered,  and  occurs  less  often;  the  pulse  grows  in  frequency 
and  fails  in  power ;  and  though  there  is  often  a  diminution  of  the  rest- 
lessness, yet,  if  able  to  talk,  the  child  will  generally  say  that  it  is  no 
better.  As  death  approaches,  though  the  respiration  grows  more 
laboured  and  more  abdominal,  yet  the  child's  suffering  generally 
diminishes,  or  a  state  of  somnolence  gradually  steals  over  it,  in  which 
it  lies  till  roused  by  an  attack  of  cough  or  by  a  paroxysm  of  dyspnoea, 
and  then,  after  a  struggle  for  breath,  it  subsides  into  its  former  drow- 
siness. The  struggles  for  breath  grow  feebler  with  each  returning 
paroxysm,  the  droAvsiness  becomes  more  profound,  and  the  patient  dies. 
It  may  be  worth  while  to  fill  up  what  is  wanting  in  this  brief  sketch 
of  the  disease,  by  the  history  of  a  case  that  displayed  many  of  its  most 
characteristic  features. 


186  ILLUSTRATIVE   CASE. 

A  little  boy,  aged  7J  years,  after  suffering  for  a  few  days  from 
general  feverishness,  with  a  constipated  state  of  the  bowels,  was 
attacked  on  the  Hth  of  April  with  incessant  short  cough  and  hurried 
breathing,  for  which  symptoms  he  was  ordered  to  be  bled  to  six  ounces, 
although  only  two  ounces  of  blood  were  obtained.  TwerVe  leeches  were 
applied  to  his  chest,  and  powders  containing  two  grains  of  calomel  and 
a  quarter  of  a  grain  of  antimony  were  given  him  every  four  hours. 
The  leech-bites  bled  profusely,  and  afforded  some  relief  to  the  dyspnoea  ; 
but,  notwithstanding  this,  the  child  passed  a  very  restless  night.  The 
next  morning  he  was  found  lying  on  his  back,  with  his  knees  drawn 
up  towards  the  abdomen,  his  face  anxious,  his  eyes  heavy,  his  skin 
dry ;  breathing  at  the  rate  of  78  inspirations  in  the  minute,  his  respi- 
ration being  often  interrupted  by  a  short  hacking  cough.  His  pulse 
was  138,  and  sharp.  He  complained  of  no  pain,  except  when  the 
abdomen  was  pressed  on ;  but  seemed  then  to  suffer  considerable 
uneasiness  about  the  epigastrium.  Percussion  of  the  front  of  the  chest 
occasioned  so  much  pain  that  it  could  not  be  practised  satisfactorily, 
and  behind  it  did  not  elicit  any  difference  between  the  two  sides. 
Throughout  the  whole  of  both  lungs  sub-crepitant  rale  was  heard  ;  it 
was  smallest  in  the  inferior  dorsal  region,  but  was  nowhere  as  small  as 
true  pneumonic  crepitus.  He  was  ordered  to  be  cupped  to  five  ounces 
between  the  shoulders,  and  tartar  emetic  was  ordered  in  quarter  of  a 
grain  doses  every  ten  minutes  until  free  vomiting  should  be  produced, 
after  which  the  powders  were  to  be  resumed.  He  took  two  grains  of 
the  tartar  emetic  without  the  slightest  effect  being  produced ;  and  on 
the  8th  his  respiration  ha^d  risen  to  98,  and  his  pulse  to  144.  On  the 
9th  his  respiration  had  sunk  to  72,  but  the  pulse  had  risen  to  156. 
The  cough  was  usually  short  and  hacking,  but  attacks  of  it,  which 
resembled  paroxysms  of  hooping-cough,  now  came  on  at  intervals. 
The  tartar  emetic  was  now  given  in  doses  of  half  a  grain  every  two 
hours,  but  no  effect  was  produced  by  it  beyond  producing  a  feeling  of 
nausea,  and  occasioning  very  slight  vomiting  twice.  For  an  hour  or 
two  early  on  the  morning  of  the  10th  he  seemed  somewhat  better ;  but 
this  improvement  soon  passed  away,  and  he  began  to  complain  of  great 
pain  in  the  chest ;  whereas  his  answer  previously  to  all  inquiries,  had 
been,  "  I  am  so  stuffed."  His  cough  was  more  severe,  and  the  mucus 
which  he  now  and  then  expectorated  with  it  was  sometimes  tinged  with 
blood.  He  passed  another  night  of  distressing  restlessness,  but  on  the 
morning  of  the  11th  grew  quieter,  and,  when  not  disturbed,  lay  on  his 
right  side  dozing.  If  spoken  to,  he  gave  intelligent  answers,  and  said, 
"I  am  no  better,"  though,  if  left  alone,  he  made  no  complaint.  He 
continued  drowsy  all  through  the  day.  Towards  evening  he  had  a  few 
minutes  of  cheerfulness,  and  spoke  of  his  own  accord  to  his  father. 
Ilis  mother  lay  down  by  his  side :  he  slept,  and  seemed  to  breathe 
"gently  :  she  slept  too ;  and  when  she  awoke  at  4  a.  M.  on  the  12th,  her 
boy  was  dead :  life  had  fled  so  quietly,  that,  though  her  arm  was  round 
him,  she  had  not  been  disturbed. 

I  need  not  detail  to  you  the  appearances  found  on  dissection  of  the 
body,  since  they  were  such  as  have  been  mentioned  as  characteristic  of 
capillary  bronchitis ;  though  the  air-tubes,  notwithstanding  their  intense 


KESULTS   OF  AUSCULTATION.  187 

injection,  contained  neither  pus  nor  false  membrane,  and  very  little 
mucus.  The  case  illustrates  the  remarks  already  made  on  the  symp- 
toms of  the  disease,  and  illustrates,  too,  the  remarkable  results  which 
percussion  and  auscultation  yield  in  this  affection,  since  sub-crepitant 
rale  continued  to  be  heard  to  the  last,  unmixed  with  bronchial  breath- 
ing or  pneumonic  crepitus ;  while,  so  long  as  percussion  could  be  prac- 
tised, it  failed  to  elicit  a  dull  sound  anywhere. 

Though  the  indications  afforded  by  auscultation  and  percussion  are 
often  sufficiently  characteristic  of  this  disease,  yet  there  are  some 
circumstances  which  may  occasionally  render  their  information  doubtful. 
The  child  is  sometimes  so  extremely  alarmed,  and  the  sensibility  of  its 
surface  so  much  increased,  that  we  have  much  difficulty  in  percussing 
the  chest :  but  we  shall  usually  be  able  to  distinguish  this  from  the 
painfulness  of  the  walls  of  the  thorax  which  attends  pleurisy,  by  find- 
ing that  it  is  not  limited  to  one  half  of  the  chest,  but  that  it  is  felt 
equally  on  either  side,  and  as  much  in  front  as  behind.  If  we  can 
succeed  in  percussing  the  chest,  however,  it  will  be  found  to  yield  a 
natural,  sometimes  even  an  increased,  degree  of  resonance,  while  little 
if  any  difference  can  be  discovered  between  the  sound  afforded  by  the 
upper,  and  that  given  out  by  the  lower  part  of  the  chest ;  or,  should 
such  be  perceived,  it  is  generally  due  to  pneumonia  having  supervened. 
The  ear  detects  a  scanty  transmission  of  air,  attended  at  first  with 
rhonchus  and  sibilus,  but  soon  with  a  universal  sub-crepitant  rale, 
heard  most  distinctly  on  the  child  making  a  deep  inspiration.  By  the 
term  sub-crepitant  rale,  it  can  hardly  be  necessary  for  me  to  say  that 
a  sound  is  meant  smaller  in  character  than  large  mucous  rale,  but 
larger  than  the  true  small  crepitation  of  pneumonia.  As  the  disease 
advances,  the  only  change  that  takes  place  consists  in  this  sub-crepitant 
rale  being  replaced  by  a  larger  mucous  rale,  the  result  not  of  any 
improvement  in  the  child's  condition,  but  of  the  air  scarcely  penetrating 
beyond  the  larger  bronchi;  for  you  will  still  hear  the  smaller  sound 
during  the  deep  inspiration  that  follows  an  attack  of  cough. 

This  form  of  bronchitis  is  one  not  only  very  dangerous,  but  likewise 
very  rapid  in  its  course  to  a  fatal  issue.  One  little  girl  in  whom  it 
came  on  while  convalescent  from  an  attack  of  measles  fourteen  days 
before,  died  within  forty-eight  hours  ;  and  the  boy  whose  case  has  been 
just  related,  died  in  less  than  four  days  from  the  appearance  of  any 
serious  symptom.  These,  however,  were  instances  of  a  rather  unusual 
rapidity  in  its  course  ;  and  from  five  to  eight  days,  which  is  the  estimate 
of  its  duration  formed  by  M.  Fauvel,  who  has  written  a  very  valuable 
essay  on  the  disease,  is  probably  not  far  from  the  true  average.1 

But  we  may  now  pass  to  the  treatment  of  bronchitis,  in  which  you 
will  find  those  general  rules  applicable  that  have  already  been  laid  down 
wThen  we  were  speaking  of  catarrh ;  while,  in  exact  proportion  to  the 
severity  of  the  symptoms,  will  be  the  care  with  which  you  must  watch 
against  the  supervention  either  of  pneumonia  or  of  that  collapse  of  the 
lung  which  is  so  grave  an  occurrence  in  early  childhood.    In  the  ordinary 

1  Recherches  sur  la  Bronchite  Capillaire,  etc.  4to.  Paris,  1840;  republished  in  a 
more  extended  form  in  Vol.  II.  of  the  "  Memoires  de  la  SocieteMedicale  d'Observation," 
8vo.  Paris,  1844. 


188  TREATMENT   OE   BRONCHITIS. 

forms  of  bronchitis,  general  depletion  is  neither  required  nor  well 
borne,  and  even  the  local  abstraction  of  blood  must  not  be  heedlessly 
resorted  to.  Leeches  may  be  applied  at  the  commencement  of 
the  attack,  if  the  child  be  strong,  and  the  febrile  disturbance  consider- 
able, and  they  may  be  employed  subsequently,  if  while  the  child's 
powers  are  still  undiminished,  the  cough  should  become  shorter  and 
more  hacking,  and  the  crepitation  either  very  general  and  abundant, 
or  smaller  in  the  lower  than  in  the  upper  lobes.  They  must  not  be 
employed  with  the  view  of  at  once  cutting  short  the  attack,  nor  must 
we  be  led  by  the  relief  afforded  by  their  first  application  to  repeat  them 
in  the  hope  of  subduing  the  disease  by  depletory  measures.  I  usually 
apply  about  four  leeches  to  a  robust  child  of  two  years  old,  and  it  is 
very  rarely  that  I  repeat  their  application.  The  situation  in  which 
they  are  applied  is  not  altogether  unimportant.  I  prefer  applying 
them  beneath  the  scapulae ;  partly  because  there  may  be  some  advan- 
tage in  drawing  blood  from  the  neighbourhood  of  that  part  of  the  lungs 
which  is  most  likely  to  become  congested,  but  still  more  because  the 
child  is  not  alarmed  as  it  would  be  if  they  were  put  on  in  front  of  the 
chest,  where  they  are  within  its  sight ;  and  because  in  this  situation  it  is 
unable  to  irritate  the  bites  by  picking  them,  as  it  is  very  apt  to  do  when 
they  are  beginning  to  heal. 

There  is  in  these  cases  the  less  excuse  for  over  depletion,  since  we 
are  possessed  in  the  tartar  emetic  of  a  most  powerful  means  of  subdu- 
ing the  disease.  In  a  healthy  child  suffering  from  bronchitis  of  moderate 
severity  1  sometimes  give  it  in  the  form  of  James's  powder,  combined 
with  a  small  quantity  of  calomel  and  ipecacuanha,  every  four  hours  for 
the  first  twenty-four  or  thirty-six  hours.  This  combination  usually 
acts  on  the  bowels  slightly,  as  well  as  on  the  skin ;  and  if  the  child  be 
now  relieved,  the  calomel  may  be  suspended,  and  small  doses  of  anti- 
monial  and  ipecacuanha  wine  may  be  given  instead,  in  a  mixture. 

A  severe  attack  of  the  disease  calls  for  the  use  of  antimony  in 
larger  doses,  so  as  to  obtain  its  emetic  effect  at  first,  and  afterwards,  by 
the  repetition  of  the  remedy  every  hour  or  two  hours,  to  keep  the  child 
for  one  or  two  days  under  its  influence.  Even  in  cases  where  the 
disease  is  not  so  severe  as  to  require  the  energetic  employment  of 
antimony,  there  is  generally  an  exacerbation  of  fever  and  dyspnoea 
towards  evening,  and  this  is  often  much  relieved  by  an  emetic  of  antimony 
and  ipecacuanha,  which  may  also  in  many  cases  be  repeated  with 
advantage  in  the  morning,  when  the  child  having  been  asleep  for  some 
hours,  during  which  the  mucus  has  been  collecting  in  the  bronchi,  it 
breathes  with  difficulty  on  awaking,  until  the  air-tubes  having  been  freely 
emptied  by  an  effort  at  vomiting,  the  air  is  once  more  enabled  freely 
to  permeate  the  lungs.  Even  in  those  cases  which  at  first  required  the 
constant  use  of  large  doses  of  antimony,  it  is  a  matter  of  importance 
to  dispense  with  them  as  soon  as  we  can  with  safety,  and  to  substitute 
the  use  of  emetics  at  intervals,  while  we  employ  some  milder  expecto- 
rant medicine  between  the  doses  of  the  emetic.  It  can  scarcely  be 
necessary  to  remind  you  that  there  are  few  medicines  which  exert  so 
depressing  an  influence  on  the  muscular  powers  as  the  tartar  emetic. — 
If  therefore  in  a  child  whose  air-tubes  are  already  nearly  filled  with 


NERVOUS   DYSrKCEA-  189 

the  abundant  secretion,  you  carry  the  depressing  effect  of  antimony  too 
far,  the  air  will  no  longer  be  inspired  with  force  sufficient  to  make  it 
reach  the  smaller  bronchi,  and  collapse  of  the  lung  will  consequently 
take  place.  It  follows,  then,  that  we  must  not  venture  to  carry  the 
depressing  effects  of  antimony  so  far  in  the  child  as  we  may  safely  do 
in  the  adult,  but  when  the  medicine  has  either  ceased  to  vomit,  or  is 
merely  regurgitated  without  effort,  we  must  either  suspend  it  altogether 
or  greatly  diminish  its  dose,  or  give  it  at  distant  intervals,  so  as  to 
obtain  its  emetic  action,  while  we  allow  time  between  the  doses  sufficient 
to  permit  the  child  perfectly  to  recover  its  powers.  The  effect  of  vomit- 
ing, on  the  other  hand,  is  useful  in  two  ways,  for  it  not  only  empties 
the  air-tubes  of  the  mucus  that  obstructs  them,  but  it  also  occasions 
several  deep  inspirations  to  be  made,  by  which  the  air  is  drawn  into  the 
remotest  parts  of  the  lungs,  and  their  tendency  to  collapse  is  thus 
prevented. 

Your  attention  has  on  more  than  one  occasion  been  called  to  the 
remarkable  tendency  of  the  nervous  system  in  early  life  to  sympathize 
in  the  affections  of  other  parts.  This  tendency  is  often  very  evident  in 
inflammation  of  the  respiratory  organs  ;  and,  accordingly,  you  must  not 
always  take  the  degree  of  dyspnoea  in  a  case  of  infantile  bronchitis  as 
a  measure  of  the  affection  of  the  lungs,  since  it  may  be  only  an  evi- 
dence of  the  sympathy  of  the  nervous  system.  If  you  treat  this 
symptom  actively,  without  having  first  inquired  into  its  import,  you  may 
destroy  your  patient.  When  first  taken  ill,  indeed,  the  child's  respira- 
tion was  hurried  and  laborious ;  you  applied  leeches  to  the  chest,  and 
gave  tartar  emetic  freely;  and  the  breathing,  which  grew  less  hurried 
and  less  oppressed,  justified  the  wisdom  of  your  treatment.  But  if  the 
respiration  again  rise  in  frequency,  and  you,  in  order  to  reduce  it 
redouble  the  activity  of  your  treatment,  you  may  be  disappointed  in 
the  effect  you  hoped  to  attain ;  the  respiration  may  grow  more  and 
more  frequent,  and  the  child  before  long  die  in  convulsions.  If  in  such 
a  case,  you  had  examined  the  patient  with  due  care,  you  wTould  proba- 
bly have  discovered  that  the  dyspnoea  was  not  associated  with  increase 
of  the  heat  of  the  skin ;  you  would  have  learned  that  it  had  varied 
much  within  a  few  hours,  sometimes  subsiding  and  then  returning  with- 
out adequate  cause  ;  you  would  not  have  detected  any  deterioration  in 
the  results  of  auscultation,  while  you  would  probably  have  perceived  in 
the  half-closed  eyes,  or  the  thumbs  drawn  into  the  palms,  signs  of  the  dis- 
turbance of  the  nervous  system. 

This  nervous  dyspnoea  sometimes  occurs  early  in  the  disease,  at  a 
time  when  active  treatment  is  evidently  indicated ;  and  while  that  plan 
is  continued,  we  shall  best  meet  this  symptom  by  applying  a  mustard 
poultice  to  the  chest,  and  by  placing  the  child  as  high  as  the  pelvis  in  a 
hot-bath.  The  evening  attacks  of  dyspnoea  are  often  more  effectively 
controlled  by  this  than  by  any  other  means.  When  these  symptoms 
come  on  at  a  more  advanced  period  of  the  disease,  or  in  a  child  previ- 
ously debilitated,  they  indicate  that  active  treatment  must  no  longer 
be  persevered  in.  The  antimony  must  be  discontinued,  or  its  dose 
greatly  reduced,  and  the  vinum  ipecacuanha,  with  small  doses  of  nitrous 
ether  and  of  the  compound  tincture  of  camphor,  should  now  be  given,1 
1  Pee  Formula  No.  10,  v.  171. 


190  TREATMENT   OF   NERVOUS   DYSPNOEA. 

or  even  small  doses  of  Dover's  powder.  The  general  restlessness  will 
be  much  relieved  by  immersing  the  whole  body  in  a  warm  bath,  which 
should  not  be  employed  at  so  high  a  temperature  as  when  used  for  its 
counter-irritant  action.  At  the  same  time  attention  must  be  paid  to 
support  the  child's  strength  by  veal-broth,  arrow-root,  or  other  nutritious 
diet. 

After  the  acute  symptoms  of  bronchitis  have  been  subdued,  the  sub- 
sequent convalescence  of  the  patient  is  often  protracted  by  the  continu- 
ance of  cough  and  wheezing  respiration, — symptoms  which  on  a  very 
slight  cause  are  apt  again  to  put  on  the  more  serious  characters  of  the 
acute  disease.  In  this  chronic  stage,  a  general  tonic  plan  of  treatment 
must  be  adopted  while  at  the  same  time  much  benefit  will  often  be 
obtained  by  the  employment  of  a  stimulating  liniment  to  the  chest.1 

(No.  11.) 

1  R  Lin.  Camph.  co.  ^j. 
'  Tinct.  Lyttse,  gij. 

Tinct.  Opii,  gij.     M.     Ft.  Linimentum. 

The  pungency  of  liniments  often  compels  us  to  employ  them  to  the  posterior  part  of 
the  chest  only,  or  to  rub  the  front  of  the  chest  with  a  much  weaker  liniment  than  that 
which  is  used  for  the  back. 

The  extract  of  bark  is  an  extremely  useful  tonic,  especially  in  cases 
where  there  exists  any  tendency  to  diarrhoea ;  while  the  wheezing  is 
often  relieved  by  the  administration  of  an  emetic  of  ipecacuanha  every 
night.  If  the  secretion  in  the  bronchi  be  very  abundant,  the  decoction 
of  senega  with  ammonia  and  tincture  of  squills,  is  often  superior  to  any 
other  medicine.2     If  the  bronchitis  have   supervened  during   dentition, 

(No.  12.) 

2  R  Decoct.  Senegae,  ^ij.  ^v. 

Ammon.  Sesquicarb.  gr.  viij. 
Tinct.  Scillee,  TT^xvj. 

Syr.  Tolutan.  ^iij.     M.     giij.  4tis  horis  e  lacte. 
For  a  child  from  two  to  three  years  old. 

you  must  not  be  surprised  at  slight  relapses  occurring  just  as  each  tooth 
approaches  the  gum.  At  other  times,  however,  bronchitic  symptoms 
continue  for  a  long  period,  and  expectoration  being  copious  and  puri- 
form,  while  the  child  loses  flesh,  and  the  relations  become  not  unnatu- 
rally apprehensive  lest  it  should  be  phthisical.  Their  fears  may  be 
well  founded,  but  at  the  same  time  that  you  would  recommend  change 
of  climate  to  some  warmer  country  in  the  winter,  or  to  the  sea-coast 
during  the  summer,  you  would,  as  I  shall  hereafter  point  out  to  you 
when  speaking  of  phthisis,  be  warranted  in  taking  a  much  more  favour- 
able view  of  such  cases  in  a  child  than  in  the  adult. 

The  general  principles  on  which  you  must  treat  the  more  grave  attacks 
of  capillary  bronchitis  have  been  laid  down  in  what  has  been  already 
said.  A  greater  degree  of  activity  in  your  treatment  is  needed ;  you 
may   even  deplete  generally,   and  follow  up  this  depletion   by   local 


SYMPTOMS   OF   THE  FIRST   STAGE   OF   PNEUMONIA.  191 

bleeding  :  but  the  caution  already  given  against  the  repeated  abstraction 
of  blood  holds  good  here.  With  reference  to  antimony,  too,  it  is  while 
the  emetic  action  of  the  remedy  continues  that  youmayhope  for  benefit 
from  its  employment ;  while  you  must  be  careful  not  to  persevere  in  its 
use  when  the  livid  face  and  faltering  pulse  show  that  the  aeration  of  the 
blood  is  nowhere  duly  carried  on.  A  blister  to  the  chest,  and  the  stimu- 
lant expectorants, — as  ammonia  and  senega  may  now  be  given,  while  the 
attempts  may  be  made,  by  emetics  of  squills  and  ipecacuanha,  to 
unload  the  bronchi  at  intervals  of  four  or  six  hours.  These  are  the 
cases,  however,  in  which,  if  you  do  not  get  the  better  of  the  disease 
at  first,  your  subsequent  remedies  will  probably  be  too  tardy  to  over- 
take it. 


LECTUEE    XVII. 

Pneumonia,  its  Symptoms  and  Treatment. — Symptoms  of  pneumonia  frequently  present 
a  mixed  character  when  it  supervenes  on  bronchitis — Idiopathic  pneumonia — approach 
of  first  stage  generally  gradual — characteristic  peculiarities  of  in  mode  of  sucking  and 
of  respiration— attack  sometimes  sudden. — Symptoms  of  second  stage — results  of 
auscultation — reasons  for  rarity  of  true  pneumonic  crepitus. — Symptoms  of  third  stage 
— convulsions  often  precede  death — their  import — occasional  imperfect  recovery — 
auscultatory  phenomena  of  this  stage. 

Nature  of  modifications  in  symptoms  produced  by  association  with  bronchitis. — Diag- 
nosis from  bronchitis — pleurisy — hydrocephalus — remittent  fever — intestinal  disorder 
during  dentition. 

Treatment — Depletion,  general  and  local ;  rules  for  each — Tartar  emetic — limitations 
as  to  its  use. — Mercury — its  importance — danger  of  salivation  very  slight. — Diet- 
antiphlogistic  in  the  early  stages — caution  as  to  sucking — stimulants  often  needed  in 
advanced  stage. — Blisters  in  general  not  desirable. 

It  was  stated  in  the  last  lecture,  that  the  supervention  of  inflammation 
of  the  substance  of  the  lungs  constitutes  one  of  the  chief  dangers  of 
infantile  bronchitis.  Pneumonia,  however,  is  not  to  be  regarded  as 
being  invariably  a  secondary  affection;  for  while  the  disease  of  the  air- 
tubes  is  in  some  cases  but  trivial,  the  pulmonary  substance  is  the  seat 
of  serious  inflammation ;  and  in  other  instances  the  air-tubes  are 
altogether  unaffected,  or  at  least  are  involved  only  in  common  with  the 
other  constituents  of  the  lung.  In  either  case,  there  are  peculiarities 
enough,  both  in  the  symptoms  observed  and  in  the  treatment  required, 
to  render  the  separate  study  of  pneumonia  indispensable. 

When  pneumonia  supervenes,  as  it  by  no  means  seldom  does,  on 
previous  catarrhal  symptoms,  the  disease  often  comes  on  insidiously, 
and  develops  itself  so  gradually  out  of  the  preceding  trivial  ailments 
that  it  is  not  possible  to  determine  the  exact  date  of  its  attack.  At 
other  times  indeed,  there  is  a  sudden  and  well-marked  increase  of  the 
fever  and  dyspnoea,  and  an  aggravation  of  all  the  symptoms,  sufficient 
clearly  to  poi^il  out  the  date  of  the  supervention  of  the  pneumonia. — 
But,  even  though  this  should  be  the  case,  yet  if  there  were  much  bron- 
chitis previously,  the  affection  of  the  air-tubes  will  often  mask  that  of 
the  lung  to  some  degree;  and  the  case  not  presenting  the  symptoms 


192  SYMPTOMS   OF   THE  FIRST   STAGE   OF  PNEUMONIA. 

either  of  bronchitis  or  of  unmixed  pneumonia,  will  assume  some  of  the 
characters  of  each,  and  merit,  both  by  the  phenomena  attending  it 
during  life,  as  well  as  by  the  appearances  found  after  death,  the  name 
of  bronchio-pnewnonia.  Cases  of  this  mixed  character  occur  most 
frequently  during  the  period  of  teething,  when  the  mucous  membranes 
are  especially  susceptible.  We  will  return  to  notice  some  of  these 
peculiarities  hereafter,  but  will  first  examine  the  symptoms  that  attend  a 
case  of  idiopathic  pneumonia,  where  the  pulmonary  substance  has 
been  affected  from  the  outset,  and  has  not  merely  become  involved  by 
the  extension  to  it  of  mischief  commencing  in  the  bronchi. 

In  almost  all  of  these  unmixed  cases,  a  condition  of  general  feverish- 
ness,  exacerbated  towards  evening,  with  fretfulness  and  pain  in  the 
head,  precede  the  more  marked  symptoms.  The  child  is  either  restless 
at  night,  or  if  it  sleep,  its  repose  is  unsound ;  it  talks  in  its  sleep,  or 
wakes  in  a  state  of  alarm.  Sometimes  from  the  very  commencement, 
at  other  times  soon  after  the  appearance  of  these  febrile  symptoms, 
cough  comes  on  ;  at  first,  short  and  hacking,  frequently  not  causing  the 
child  any  uneasiness,  and  so  slight  as  scarcely  to  excite  the  notice,  and 
not  at  all  to  awaken  the  anxiety  of  the  parents.  Loss  of  appetite  and 
increase  of  thirst  are  early  observable:  the  bowels  are  usually  constipated, 
and  vomiting  is  not  infrequent,  especially  in  infants  at  the  breast.  The 
tongue  and  lips  are  at  the  same  time  of  a  florid  red ;  the  tongue  is  less 
moist  than  usual,  and  is  generally  coated  in  the  middle  with  a  thickish 
white  fur.  In  these  symptoms,  indeed,  there  is  but  little  to  mark  the 
real  nature  of  the  case,  or  to  point  to  the  organ  whose  disease  has 
kindled  the  fever  in  the  system  ;  for  the  slight  cough,  if  not  overlooked, 
may  yet  be  attributed  to  irritation  of  the  bronchi,  sympathetic  with 
derangement  of  the  stomach  or  intestines.  The  respiration,  too,  is  not 
always  much  hurried  at  this  early  period ;  while,  in  the  young  child, 
both  its  frequency,  and  that  of  the  pulse,  is  much  modified  by  position ; 
and  the  results  of  auscultation  are  not  uniform,  and  may  sometimes 
afford  no  information  at  all.  Even  now,  however,  there  are  some  signs 
which  to  the  attentive  observer  will  convey  much  information,  and 
information  all  the  more  valuable  from  our  being  furnished  with  it 
chiefly  in  those  young  infants  in  whom  the  diagnosis  of  this  disease  is 
attended  with  most  difficulty.  The  seat  of  the  mischief  is  shown  to  be 
in  the  respiratory  organs  by  the  child  no  longer  breathing  through  the 
nares,  while  the  tongue  is  applied  to  the  roof  of  the  mouth,  as  it  does 
in  health  ;  but  by  its  breathing  through  the  open  mouth  also,  whence 
the  tongue  early  acquires  an  unusual  degree  of  dryness.  The  same 
inability  to  respire  comfortably  through  the  nares  causes  the  child  to 
suck  by  starts :  it  seizes  the  breast  eagerly,  sucks  for  a  few  moments 
with  greediness,  then  suddenly  drops  the  nipple,  and  in  many  instances 
begins  to  cry.  As  the  disease  advances,  these  peculiarities  in  the  mode 
of  sucking  and  of  respiration  often  become  more  striking ;  but  it  is  at 
its  onset  that  they  are  most  valuable,  since  then  we  have  fewer  indica- 
tions to  lead  us  right. 

It  is  not,  however,  thus  gradually  that  pneumonia  always  comes  on ; 
for  sometimes  a  child  who  had  gone  to  bed  well,  or  merely  a  little  poorly, 
wakes  in  the  night  in  a  state  of  alarm,  refusing  to  be  pacified,  with  a 


RESULTS   OF   AUSCULTATION.  193 

flushed  face  and  burning  skin,  and  hurried  breathing  and  short  cough. 
This  sudden  supervention  of  pneumonia  is  not  so  often  met  with  among 
infants  at  the  breast  as  among  children  from  two  to  four  years  old. 
Often,  though  not  always,  this  severe  onset  of  the  disease  has  appeared 
to  depend  on  the  pneumonia  being  associated  with  extensive  inflammation 
of  the  pleura ;  but  sometimes  the  symptoms  wThich  at  first  seemed  so 
threatening,  soon  subside,  and  the  affection,  in  its  subsequent  stages, 
presents  no  peculiarity,  and  is  not  by  any  means  remarkable  for  its 
severity. 

This  first  stage  of  pneumonia  passes,  for  the  most  part,  by  degrees 
into  the  second,  in  which  the  nature  of  the  affection  is  generally  obvious 
to  all.  The  momentary  cheerfulness  which  before  existed  has  now 
passed  away ;  infants  now  no  longer  wish  to  be  removed  from  the  cradle, 
or  from  the  recumbent  posture  in  their  nurse's  arms,  and  older  children 
have  quite  lost  all  interest  in  their  play ;  they  become  drowsy,  ask  to  be 
put  to  bed,  and  cry  if  taken  up.  The  hurry  of  the  respiration  is  now 
abundantly  evident ;  the  alse  nasi  are  dilated  with  each  inspiration,  the 
abdomincl  muscles  are  brought  into  play  to  assist  in  its  performance, 
and  any  change  of  posture  renders  the  breathing  more  laboured  and 
more  hurried.  The  cough  has  become  much  more  frequent ;  it  is  still 
hard,  sometimes  is  evidently  painful,  so  that  the  child  cries  with  each 
cough  ;  at  other  times  it  is  an  almost  constant  short  hack.  The  bright 
flush  of  the  face,  and  the  florid  tint  of  the  lips,  have  gone,  but  the  heat 
of  skin  continues;  for  the  persistence  of  an  almost  unvarying  high 
temperature  throughout  its  course,  is,  as  M.  Roger  has  shown,  one  of 
the  characteristics  of  the  pneumonia  of  the  child  as  well  as  of  that  of  the 
adult.  It  is  a  pungent  heat,  which  becomes  more  sensible  the  longer 
the  hand  is  kept  in  contact  with  the  surface ;  and  so  great  is  the  eleva- 
tion of  temperature,  that  M.  Roger  found  it  average  almost  104°  Fah. 
in  ninety-seven  experiments,  while  in  some  cases  it  greatly  exceeded  this 
degree.  Though  so  intense,  however,  this  heat  is  unequal  at  different 
parts, — the  extremities  being  cool,  or  even  cold,  while  the  body  is  hot ; 
but  there  is  no  moisture  on  any  part  of  the  skin.  The  face  now 
assumes  a  puffed,  heavy,  but  anxious  appearance,  and  when  the  child  is 
very  young,  or  the  pneumonia  very  extensive,  the  lips  put  on  a  livid 
hue,  which  is  also  very  evident  around  the  mouth,  while  the  face 
generally  is  pale.  The  thirst  usually  continues  very  urgent,  but  chil- 
dren at  the  breast  still  vomit  the  milk.  This  is  apparently  owing  to 
their  thirst  being  so  urgent  as  to  lead  them  to  suck  too  greedily,  and 
thus  overload  their  stomach,  since  while  they  generally  vomit  almost 
immediately  after  leaving  the  breast,  they  do  not  reject  small  quantities 
of  fluid  given  them  from  a  cup  or  spoon.  The  disease  of  the  lungs 
now  betrays  itself  most  strikingly  in  children  at  the  breast,  for  as  often 
as  they  attempt  to  suck,  the  respiration  becomes  at  once  greatly  hurried  ; 
they  drop  the  nipple,  panting,  from  their  mouth,  or,  having  seized  it, 
have  not  breath  sufficient  to  make  the  vacuum  necessary  to  bring  the 
flow  of  milk. 

The  results  of  auscultation,  though  variable,  are  now  sufficiently 
obvious.  Crepitation  is  now  heard,  often  in  both  lungs,  and  generally 
in  their  lower  and  posterior  parts — seldom,  however,  the  minute  crepitus 

13 


194  SYMPTOMS   OP   THE   THIRD    STAGE   OF   PNEUMONIA. 

such  as  we  hear  in  the  pneumonia  of  the  adult,  but  that  sound  known  as 
the  sub  crepitant  rale.  The  comparative  rarity  of  true  pneumonic 
crepitus  in  inflammation  of  the  lungs  in  infancy  is  a  point  not  to  be  lost 
sight  of:  often,  however,  if  you  keep  your  ear  to  an  infant's  chest,  and 
wait  till  it  takes  an  unusually  deep  inspiration,  you  will  hear  the  true 
crepitus  of  pneumonia  just  for  a  moment  when  the  air  enters  the  pul- 
monary vesicles ;  and  then  again  you  will  lose  it  when  the  child  breathes 
as  it  was  doing  before,  and  you  will  hear  only  the  sub-crepitant  rale. 
If  the  inflammation  have  attacked  only  one  lung,  you  will  perhaps  be 
struck  by  the  loud  puerile  breathing  in  the  healthy  organ,  which  is  thus 
compelled  to  perform  a  double  function.  If  both  be  involved,  you  may 
almost  overlook  the  disease,  since  you  have  not  the  aid  afforded  by 
contrast ;  unless,  as  it  sometimes  happens,  the  mischief  on  the  one  side 
is  so  far  advanced  as  to  cause  bronchial  breathing,  while  on  the  other 
side  crepitation  alone  is  audible.  This  bronchial  breathing  is  sometimes 
heard  associated  with  sub-crepitant  rale,  or  with  large  crepitation,  while 
at  other  times  the  ear  detects  nothing  but  the  whiff  of  air  through  the 
larger  air-tubes  ;  and  often  this  alone  is  audible  on  an  ordinary  inspi- 
ration, while  on  a  deep  breath  being  taken,  the  sub-crepitant  rale  will 
be  at  once  perceptible.  In  the  child  we  lose  all  the  information  which, 
in  the  adult,  is  afforded  by  the  different  modifications  of  the  voice  sound : 
for  the  shrill  or  querulous  tone  of  a  suffering  child,  and  the  words  often 
uttered  in  very  different  keys,  yield  even  when  the  child  is  old  enough 
to  talk  well,  results  far  too  uncertain  to  be  trustworthy. 

Percussion  sometimes  yields  a  very  manifest  dullness  on  the  affected 
side  ;  and  this  dulness  is  usually  most  evident  in  the  infra-scapular 
region.  At  other  times,  however,  no  such  marked  results  are  afforded, 
but  the  lower  parts  of  the  chest  yield  a  somewhat  duller  sound  than  the 
upper,  and  the  impression  communicated  to  the  finger  is  that  of  greater 
solidity  below  than  above  the  scapula.  This  last  sign  is  often  very 
valuable,  since  it  may  be  perceived  at  a  time  when  the  ear  cannot 
clearly  detect  actual  dulness  on  percussion. 

Death  may  take  place  in  this,  the  second  stage  of  pneumonia,  if  a  very 
extensive  portion  of  lung  have  been  involved  in  the  disease,  or  if  it  be 
associated  with  much  inflammation  of  the  pleura,  or  if  the  pneumonia 
have  been  grafted  on  severe  bronchitis.  The  pneumonia  which  super- 
venes on  measles,  or  which  comes  on  in  a  child  debilitated  by  previous 
illness,  sometimes  terminates  unexpectedly  in  this  stage,  and  on  an 
examination  of  the  body  after  death  the  lung  is  found  scarcely  to  have 
passed  beyond  the  first  stage  of  pneumonia,  except  in  a  few  portions  of 
but  limited  extent:  though  still  larger  tracts  will  probably  be  found  in 
the  state  of  carnification,  and  to  the  sudden  supervention  of  this  condition 
the  fatal  event  is  probably  in  great  measure  due.  It  is  important,  too, 
to  bear  in  mind  that  in  weakly  children  a  pneumonia  of  even  very  small 
extent  will  often  prove  fatal :  hence  the  great  importance  of  watching 
most  sedulously  against  all  those  intercurrent  affections  of  the  lungs 
which  come  on  in  the  course  of  diarrhoea,  measles,  remittent  fever,  &c. 

But  the  pneumonia  may  be  free  from  any  of  the  above-named  compli- 
cations, and  then,  if  unchecked  by  treatment,  it  will  pass  into  the  third 
stage.     The  respiration  now  becomes  more  laboured,  and  though  its  fro- 


RESULTS   OP   AUSCULTATION.  195 

quency  is  sometimes  diminished  it  will  be  found  to  have  become  irregular  ; 
several  short  and  hurried  inspirations  being  followed  by  one  or  two  deeper, 
and  at  longer  intervals,  and  these  again  by  hurried  breathing.  The 
cough  sometimes  ceases  altogether,  or  if  not,  it  is  less  frequent,  and 
looser,  since  it  is  now  produced  by  the  child's  efforts  to  clear  the  larger 
air-tubes  from  the  accumulating  secretions.  The  voice  is  often  lost,  the 
patient  speaking  only  in  a  hoarse  whisper ;  while  children  who  were  just 
learning  to  talk  will  frequently  maintain  complete  silence,  as  if  conscious 
that  they  have  no  breath  to  waste  in  words.  The  face  looks  sunken,  the 
extremities  are  cold,  and  though  the  trunk  retains  its  high  temperature 
almost  to  the  last,  yet  the  skin  often  loses  somewhat  of  its  previous 
dryness,  and  clammy  sweats  break  out,  especially  about  the  head.  The 
pulse  is  extremely  frequent  and  small,  and  the  beats  so  run  into  each 
other  that  it  is  almost  impossible  to  count  them.  The  child  is  sometimes 
very  restless  at  intervals,  tossing  about  from  side  to  side  as  much  as  its 
reduced  powers  will  permit ;  but  it  usually  lies  in  a  state  of  half  con- 
sciousness, though  sensible  when  spoken  to,  and  fretful  if  disturbed. 
If  raised  hastily  from  the  recumbent  posture,  or  if  put  to  the  breast, 
the  great  increase  of  dyspnoea  which  is  immediately  produced  shows 
how  seriously  the  respiratory  organs  are  affected.  In  many  cases,  too, 
the  livid  hue  of  the  face  and  of  the  nails  is  a  further  proof  of  the  great 
impediment  which  exists  to  the  decarbonization  of  the  blood ;  and  once 
I  saw  purpurous  spots  appear  on  the  arms  and  hands  thirty-six  hours 
before  the  death  of  a  previously  healthy  child  of  a  year  old,  in  whom  an 
attack  of  idiopathic  pneumonia  terminated  fatally  on  the  seventeenth  day. 
This  condition  seldom  lasts  above  two  or  three  days  ;  for  either  life 
becomes  gradually  extinct,  without  the  supervention  of  any  new  symptom, 
or  convulsions  occur,  which  are  followed  by  fatal  coma,  or  the  child 
recovers  from  it  for  a  few  hours  only  to  suffer  a  second  attack  of  con- 
vulsions, and  a  return  of  coma,  in  which  it  dies.  It  can  scarcely  be 
necessary  to  remind  you  of  what  was  said  some  time  since  with  reference 
to  the  import  of  convulsions,  and  to  their  being  in  many  cases  merely 
a  token  of  disturbance  of  the  function  of  the  brain,  such  as  delirium  ia 
the  adult.  The  former  symptom  in  the  child,  and  the  latter  in  the 
adult,  betoken  in  a  case  of  pneumonia  thatHhe  brain  is  suffering  from 
the  circulation  through  it  of  imperfectly  aerated  blood. 

The  third  stage,  however,  does  not  always  advance  thus  uninter- 
ruptedly to  a  fatal  issue,  but  a  kind  of  imperfect  recovery  sometimes 
takes  place.  A  diminution  is  obvious  in  the  more  alarming  symptoms ; 
the  patient  begins  to  express  some  desire  for  food  as  well  as  for  drink, 
and  even  has  occasional  gleams  of  cheerfulness.  The  cough,  which  in 
many  instances  had  almost  or  altogether  ceased,  returns,  but  is  short 
and  hacking,  although  there  is  sometimes  a  good  deal  of  mucus  in  the 
larger  air-tubes.  The  dyspnoea  is  no  longer  urgent,  though  the  breath 
is  habitually  short.  The  skin  is  hot,  dry,  and  harsh,  and  evening 
exacerbations  of  fever  often  occur  ;  the  tongue  is  red,  dry,  and  some- 
times chapped,  or  presents  small  aphthous  ulcers  at  its  edges  ;  diarrhoea 
is  not  unfrequent ;  the  child  wastes  daily,  and  dies  in  the  course  of  a 
week  or  two,  worn  out  and  exceedingly  emaciated. 

The  auscultatory  signs  of  this  third  stage  of  pneumonia  are  in  the 


196  BRONCHIO-PNEUMONIA. 

main  those  of  the  second  stage,  except  that  the  bronchial  breathing 
usually  becomes  both  more  distinct  and  more  extensive,  occupying  situa- 
tions where  either  the  sub-crepitant  rale,  or  even  large  crepitation,  had 
previously  been  heard.  As  it  extends,  too,  it  becomes  audible  in  front 
as  well  as  behind,  and  both  it,  and  dulness  on  percussion,  may  be  per- 
ceived in  the  infra-mammary  as  well  as  in  the  infra-scapular  region,  to 
which,  at  first,  they  are  almost  always  limited.  This  bronchial  breathing 
is  generally  much  more  extensive  on  one  side  than  on  the  other,  and 
sometimes  it  is  heard  throughout  the  whole  posterior  part  of  one  side 
of  the  chest ;  but  I  never  found  bronchial  breathing  confined  to  the 
upper  part  of  one  lung,  except  in  cases  where  there  existed  previous 
tubercular  disease  of  the  organ,  and  then  the  pulmonary  tissue  may 
become  solidified  under  the  influence  of  an  amount  of  disease  which 
otherwise  would  be  inadequate  to  produce  this  result. 

The  symptoms  that  attend  the  third  stage  of  the  disease  usually  are 
the  result  of  the  lung  having  passed  into  the  state  of  suppuration.  I 
say  usually,  for  sometimes  recovery  eventually  takes  place  even  from  a 
condition  apparently  desperate,  and  in  such  cases  the  degree  to  which 
disorganization  of  the  lung  had  actually  advanced  must  always  remain 
uncertain. 

The  results  of  auscultation  do  not  help  us,  any  more  than  in  the 
adult,  to  determine  with  certainty  the  amount  of  injury  that  the  lung 
has  received,  while  we  are  deprived  almost  entirely  of  that  information 
which  in  the  grown  person  is  afforded  us  by  the  changes  in  the  appear- 
ance of  the  sputa.  In  some  cases  of  rapidly  fatal  pneumonia  I  have 
seen  a  frothy  secretion  collect  about  the  mouth ;  but  this  was  evidently 
not  furnished  by  the  air-tubes,  but  was  merely  the  saliva  which  the 
child  was  unable  either  to  spit  out  or  to  swallow.  The  cough  of  pneu- 
monia being  generally  short  and  not  paroxysmal,  we  have  not  so  much 
chance  of  seeing  the  sputa  as  in  the  case  of  acute  bronchitis,  and  chil- 
dren even  of  five  or  six  years  old  seldom  spit  out  the  matters  that  they 
expectorate,  but  almost  always  swallow  them. 

When  resolution  of  a  hepatized  lung  takes  place,  the  changes  in  the 
physical  signs  of  the  disease  are  much  the  same  as  are  perceived  in  the 
adult.  I  have  not,  however,  in  any  instance  detected  a  return  of  true 
pneumonic  crepitation,  but  sub-crepitant  rale  in  most  cases  became 
audible,  and  in  a  few  instances  large  crepitation.  In  either  case 
mucous  rale  was  eventually  heard,  and  it  often  continued  for  many  days 
after  the  lung  had  in  other  respects  recovered  its  natural  condition  ; 
apparently  much  as,  in  the  pneumonia  of  the  adult,  prolonged  expiration 
often  persists  for  a  long  time  after  all  the  other  signs  of  disease  have 
disappeared. 

At  the  commencement  of  this  lecture  reference  was  made  to  cases  in 
which  the  symptoms  of  pneumonia  are  modified  by  those  of  the  bron- 
chitis with  which  it  is  associated.  In  such  cases  there  is  from  the  very 
outset  a  marked  degree  of  dyspnoea  and  distress,  and  the  face  presents 
from  the  first  a  livid  hue.  The  cough  is  less  short  than  in  simple  pneu- 
monia, but  it  comes  on  in  paroxysms  which  greatly  distress  the  patient : 
the  respiration  is  more  hurried  and  more  irregular,  and  this  irregularity 
comes  on  at  an  earlier  stage  of  the  disease.     Large  crepitation  and  sub- 


DIAGNOSIS   OF   PNEUMONIA.  197 

crepitant  r&le  are  generally  heard  very  extensively  in  both  lungs,  but 
true  pneumonic  crepitation  is  unusual.  A  preponderating  affection  of 
the  lower  lobes  is  seldom  perceptible;  and  since  these  cases  usually 
tend  to  a  rapid  termination,  death  sometimes  takes  place  before  either 
dulness  on  percussion,  or  bronchial  breathing,  has  become  distinctly 
audible. 

Such  are  the  characters  generally  presented  by  pneumonia  in  early 
life,  and  these  are  usually  so  well  marked  as  to  render  it  impossible 
either  to  overlook  the  disease  or  to  mistake  its  symptoms  for  those  of 
some  other  malady.  This,  however,  is  not  invariably  the  case  even 
when  the  inflammation  of  the  lungs  occurs  as  an  idiopathic  affection, 
while  in  those  instances  in  which  it  comes  on  in  the  course  of  other  dis- 
eases, it  very  often  remains  latent,  and  much  acuteness  of  perception, 
as  well  as  much  patient  observation,  are  necessary  for  its  detection. 
We  will  pass  over  for  the  present  the  consideration  of  secondary  pneu- 
monia, since  to  understand  all  the  varieties  that  it  presents  would  re- 
quire a  previous  acquaintance  with  those  diseases  in  the  course  of  which 
the  inflammation  of  the  lungs  supervenes.  "When  we  come  to  the  study 
of  hooping-cough,  croup,  measles,  remittent  fever,  &c,  I  will  endeavour 
to  point  out  the  period  at  which,  in  each  of  these  maladies,  pneumonia 
is  most  to  be  apprehended,  and  the  symptoms  that  indicate  its  attack ; 
but  to-day  we  will  confine  our  notice  to  those  cases  in  which  the  inflam- 
mation of  the  respiratory  organs  occurs  as  an  idiopathic  affection.     » 

The  points  of  difference  between  pneumonia  and  bronchitis  have 
already  been  dwelt  on  so  fully  as  to  render  it  unnecessary  to  recapitu- 
late them.  In  many  cases  they  are  too  obvious  to  admit  of  your 
falling  into  error,  but  in  others  they  are  so  shaded  off  that  it  is  difficult 
to  determine  whether  the  characters  of  one  or  of  the  other  predomi- 
nate ;  and  we  are  forced  to  conclude  that  the  two  exist  together,  the 
one  obscuring  the  otherwise  well-marked  features  of  the  other. 

In  the  child,  as  in  the  adult,  some  degree  of  pleurisy  exists  in  a  large 
proportion  of  cases  of  pneumonia,  though  sometimes  so  slight  as  to  be 
scarcely  noticed;  whilst  in  other  cases,  though  a  little  friction  sound 
may  be  heard  for  a  short  time,  yet  it  is  evident  that  the  danger  to  life 
is  occasioned  by  the  mischief  in  the  lung,  and  not  by  the  affection  of 
the  pleura.  Sometimes,  however,  inflammation  of  the  pleura  is  the 
chief,  if  not  the  sole,  cause  of  the  patient's  danger,  and  hence  it  is 
desirable  to  know,  even  at  the  outset,  whether  the  lung  or  its  investing 
membrane  is  the  part  chiefly  affected. 

An  attack  of  pleurisy  is  much  oftener  marked  by  complaint  of  severe 
pain  in  the  chest,  than  is  an  attack  of  pneumonia ;  or  if  the  child  be 
unable  to  express  its  feelings,  the  seizure  is  not  infrequently  announced 
by  violent  and  continued  screaming.  Sympathetic  disturbance  of  the 
brain  is  more  frequent  and  more  severe  at  the  onset  of  an  attack  of 
pleurisy  than  of  pneumonia,  and  the  attendant  restlessness  greater. 
Auscultation,  too,  fails  to  discover  the  crepitant  or  sub-crepitant  rale 
which  characterises  pneumonia,  but  air  enters  the  lung  on  the  affected 
side  much  less  freely  than  on  the  other,  and  a  friction  sound  may  per- 
haps be  distinguished ;  though  this  is  by  no  means  invariable,  and  even 
when  present  it  may  easily  be  mistaken  for  rhonchus.     It  may  be  laid 


108  DIAGNOSIS   OF  PNEUMONIA. 

down  as  a  rule,  subject  to  but  few  exceptions,  that  whenever  a  child  is 
suddenly  seized  with  symptoms  which,  while  they  indicate  some  affec- 
tion of  the  lungs,  are  yet  unattended  with  the  auscultatory  signs  of 
pneumonia,  the  disease  from  which  it  is  suffering  is  pleurisy  ;  and  this 
probability  is  rendered  almost  a  certainty,  if,  while  the  child  bears 
percussion  on  one  side  of  the  chest,  it  cries  and  struggles  on  the 
slightest  attempt  at  percussion  of  the  opposite  side. 

The  error  of  taking  a  case  of  pneumonia  for  one  of  pleurisy,  how- 
ever, or  the  opposite,  is  of  comparatively  little  moment :  but  there  are 
other  diseases  for  which  pneumonia  may  be  taken,  in  which  the  error 
of  diagnosis  will  lead  to  serious,  and  perhaps  fatal,  mistakes  in  treat- 
ment. 

These  mistakes,  too,  may  be  made  at  almost  any  stage  of  the  disease. 
At  the  commencement  pneumonia  may  be  taken  for  incipient  hydroce- 
phalus. The  vomiting,  the  pain  in  the  head,  the  restless  nights,  with 
talking  in  the  sleep,  which  attend  the  onset  of  almost  all  the  acute 
affections  of  childhood,  the  fever,  and  the  constipated  state  of  the 
bowels  common  to  both  diseases,  lead  to  this  error.  The  cough  in  some 
cases  of  pneumonia  is  so  slight  as  scarcely  to  be  noticed,  while  even  if 
present  it  may  be  taken  for  that  sympathetic  cough  which  is  sometimes 
present  in  the  early  stages  of  hydrocephalus ;  and  the  child,  if  ques- 
tioned, may  complain  of  his  head,  and  of  nothing  else.  But  still  there 
are  circumstances  which  would  lead  the  attentive  observer,  independ- 
ently of  auscultation,  to  detect  the  real  nature  of  the  case.  The 
vomiting  that  ushers  in  an  attack  of  pneumonia,  though  sometimes 
violent,  seldom  continues  long,  and  is  unattended  with  that  permanent 
nausea  and  irritability  of  the  stomach  which  are  so  marked  in  the  first 
stage  of  hydrocephalus.  The  evacuations  in  pneumonia  are  natural ; 
the  tongue  is  of  a  much  more  vivid  red  than  in  hydrocephalus ;  the 
pulse  is  much  more  frequent,  the  heat  of  skin  far  greater,  and  more 
remarkable  on  the  trunk  than  about  the  head,  and  the  thirst  is  gene- 
rally urgent.  If  these  indications,  however,  be  overlooked  at  the  com- 
mencement of  the  attack,  and  if  auscultation,  by  which  the  error  might 
still  be  set  right,  be  neglected,  it  is  probable  that  each  subsequent 
occurrence  will  be  misinterpreted,  and  that  the  real  nature  of  the 
disease  will  not  be  understood  until  it  is  revealed  by  the  post-mortem 
examination.  More  or  less  sympathetic  affection  of  the  head  is  seldom 
wanting  in  pneumonia  to  confirm  the  preconceived,  erroneous,  notion  ; 
while,  as  the  child  grows  worse,  the  difficulties  in  the  way  of  making  a 
careful  auscultation  increase.  Convulsions  sometimes  occur  even 
several  days  before  the  patient's  death,  and  the  head  symptoms  may 
appear,  especially  to  a  prejudiced  observer,  to  be  much  more  striking 
than  any  which  indicate  affection  of  the  lungs. 

It  sometimes  happens  that  the  sympathetic  disturbance  of  the  stomach 
and  bowels  is  so  considerable  as  to  obscure  the  chest  symptoms,  and  the 
case  is  taken  for  one  of  enteritis;  or  perhaps,  if  the  heat  of  skin  and 
sensorial  disturbance  be  considerable,  for  one  of  remittent  fever.  The 
vomiting  at  the  outset  of  the  disease,  the  pain  referred  to  the  abdomen, 
with  the  evident  increase  of  discomfort  on  pressure,  the  red  tongue, 
with  its  disposition  to  dryness,  and  the  diarrhoea  that  exists  in  these 


DIAGNOSIS   OF   PNEUMONIA — ITS    TREATMENT.  199 

rather  exceptional  cases  of  pneumonia,  are  the  circumstances  which 
tend  to  lead  into  error  ;  and  this  error  may  be  confirmed  on  the  prac- 
titioner finding  that  at  least  temporary  relief  follows  the  application  of 
leeches  and  poultices  to  the  abdomen.  With  reference  to  the  complaint 
of  pain  in  the  belly,  which  seems  often  to  have  a  large  share  in  inducing 
this  error,  it  must  be  remembered  that  the  statements  of  children  with 
reference  to  the  seat  of  pain  are  very  vague,  and  that  they  frequently 
speak  of  the  belly  when  they  mean  the  chest;  while  the  impediment  to 
the  descent  of  the  diaphragm  occasioned  by  pressure  on  the  abdomen, 
especially  if  this  pressure  be  either  sudden  or  considerable,  will  almost 
always  excite  expressions  of  uneasiness  when  the  organs  of  respiration 
are  in  any  way  aiFected.  It  is  in  careful  auscultation  that  you  will 
find  your  chief  safeguard  against  these  mistakes ;  but  you  will  find 
besides,  that,  by  accustoming  yourselves  to  look  not  at  one  or  two 
prominent  symptoms  only,  but  at  the  relation  which  each  bears  to  the 
other,  many  of  the  chief  difficulties  in  the  way  of  forming  a  correct 
diagnosis  will  disappear. 

It  may  perhaps  seem  to  you  that  much  of  this  is  very  dry  and  rather 
needless  detail ;  but  unfortunately  my  own  case-books  would  enable  me 
to  illustrate  each  of  these  errors  of  diagnosis,  against  which  it  is  my 
endeavour  to  guard  you.  One  more  caution  I  would  offer  you,  and  that 
is,  not  to  overlook  the  pneumonia  which  sometimes  comesjon  in  children 
ivhile  teething.  Unless  you  be  on  the  watch  for  it,  its  early  symptoms 
will  probably  fail  to  excite  your  apprehension,  since  they  will  be 
regarded  as  the  result  of  that  sympathetic  irritation  of  the  air-tubes, 
which  so  often  accompanies  dentition,  and  the  time  for  action  will  thus 
be  allowed  to  pass  unemployed.  The  disease  comes  on  most  frequently 
in  weakly  children,  is  unattended  by  much  constitutional  reaction,  and 
often  runs  a  somewhat  chronic  course  ;  while  its  nature  is  further 
obscured  by  the  tendency  to  diarrhoea  which  exists  during  dentition, 
and  which  is  now  excited  by  the  thoracic  affection.  The  purging  often 
becomes  the  most  striking  symptom,  and  all  means  are  employed  to 
suppress  it,  and  to  check  the  vomiting  which  generally  attends  it. 
These  efforts,  however,  are  unavailing ;  the  child  wastes  daily,  and  its 
skin  hangs  in  wrinkles  about  its  attenuated  limbs,  while  the  abdomen 
becomes  tumid  from  the  collection  of  flatus  in  the  large  intestines,  and 
tender  on  pressure,  and  the  tongue  grows  red,  dry,  and  chapped,  or 
covered  with  aphthous  ulcers.  The  cough  now  perhaps  attracts  notice  ; 
but  both  it  and  the  bronchial  breathing  in  the  lungs  are  probably  looked 
on  as  indications  of  phthisis,  and  the  doctor  consoles  himself  with  the 
belief  that  he  has  failed  to  cure  the  disease  because  it  was  irremediable. 
At  last  the  child  is  worn  out,  and  dies,  and  great  is  the  surprise  to  find 
no  tubercle  in  any  part  of  the  body,  no  disease  in  the  intestines, 
but  pneumonia,  with  purulent  infiltration  in  both  lungs, — a  disease 
which  ought  to  have  been  detected,  and  which  probably  might  have 
been  cured. 

We  come  now,  in  conclusion,  to  the  consideration  of  the  treatment 
of  pneumonia  in  children.  The  main  principles  that  guide  us  are  the 
same  as  in  inflammation  of  the  lungs  in  the  adult,  and  our  chief  reliance 


200  TREATMENT   OF  PNEUMONIA — DEPLETION — 

is  placed  on  the    same   remedies  in   both    eases — namely,  depletion, 
calomel,  and  tartar  emetic. 

You  will  find  that  many  of  the  continental  writers  on  the  diseases  of 
children  are  greatly  opposed  to  the  abstraction  of  blood  in  cases  of 
infantile  pneumonia,  and  that  some  even  assert  that  it  invariably  debili- 
tates the  system,  and  accelerates  the  patient's  death.  This  opinion, 
however,  has  been  formed  by  the  observation  of  those  secondary  pneu- 
monias which  are  of  such  frequent  occurrence  among  the  inmates  of  the 
Children's  Hospital  at  Paris;  and  therapeutical  conclusions  deduced 
from  cases  of  so  peculiar  a  kind  as  are  there  presented,  cannot  be 
framed  into  rules  for  the  general  guidance  of  our  conduct.  But  much 
misapprehension  has  also  arisen  from  confounding  the  condition  of  col- 
lapse of  the  lung  with  that  of  its  solidification  from  true  inflammatory 
action  ;  and  the  mistaken  pathology  has  led  to  mistaken  treatment. 
In  the  management  of  cases  of  idiopathic  pneumonia  occurring  in  pre- 
viously healthy  children,  whatever  be  their  age,  depletion  is  as  impor- 
tant a  remedy  as  in  the  adult :  nor  will  the  most  energetic  employment 
of  any  other  antiphlogistic  measures  enable  us  safely  to  dispense  with 
its  use.  In  a  healthy  child  of  two  years  old,  a  vein  may  be  opened  in 
the  arm,  and  ^iv.  of  blood  may  be  allowed  to  flow,  provided  that  faint- 
ness  be  not  earlier  produced,  without  there  being  any  reason  for  us  to 
apprehend  that  the  plan  we  are  adopting  is  too  energetic.  It  often 
happens  that  the  child  faints  before  this  quantity  of  blood  has  been 
drawn,  while  in  other  cases,  not  above  one  or  two  ounces  of  blood  can 
be  obtained.  Still,  whenever  the  patient  is  seen  at  the  commencement 
of  the  attack,  general  depletion  is  desirable,  even  though  it  should  be 
necessary  to  follow  it  up  by  local  bleeding ;  for  the  immediate  effect 
which  it  produces  is  greater  than  that  which  follows  local  depletion, 
and  the  quantity  of  blood  abstracted  by  it  is  definite  ;  while,  if  both 
the  nurse  and  the  medical  attendant  understand  how  to  manage  chil- 
dren, it  may  be  so  conducted  as  to  cause  them  but  little  excitement  or 
alarm.  If  but  very  little  blood  can  be  drawn  from  the  arm,  or  if,  as 
is  not  seldom  the  case  with  infants  under  two  years  of  age,  it  be  not 
possible  to  find  a  vein,  depletion  must  be  accomplished  by  means  of 
leeches,  which,  for  reasons  already  stated,  it  is  desirable  to  apply 
beneath  the  scapulae.  How  great  soever  may  have  been  the  relief 
which  followed  the  first  bleeding,  it  is  not  always  permanent ;  and 
hence  the  child  should  be  seen  again  in  from  six  to  eight  hours ;  and 
if  the  symptoms  appear  to  be  returning  with  anything  of  their  former 
severity,  depletion  must  be  repeated ;  though  then  local  blood-letting 
is  to  be  preferred  to  venesection,  even  in  cases  in  which  bleeding  from 
the  arm  had  been  resorted  to  in  the  first  instance.  It  must  never  be 
forgotten,  that  in  the  child,  as  well  as  in  the  adult,  no  subsequent  care 
can  make  up  for  the  inefficient  treatment  of  the  early  stage  of  pneu- 
monia :  if  the  first  twenty-four  hours  be  allowed  to  pass  while  you  are 
employing  inadequate  remedies,  the  lung,  which  at  first  was  merely 
congested,  will  have  become  solid,  and  recovery,  if  it  take  place  even- 
tually, will  be  tardy,  and  perhaps  imperfect.  On  the  other  hand, 
cases  that  set  in  with  the  greatest  severity  sometimes  appear  to  be  at 
once  cut  short  by  free  depletion  ;  the  violent  symptoms  being  arrested, 


USE  OF  TARTAR  EMETIC.  201 

and  recovery  going  on  uninterruptedly,  almost  without  the  employment 
of  any  other  remedy. 

In  the  treatment  of  the  pneumonia  of  the  adult  we  are  accustomed 
to  follow  up  the  advantages  gained  by  depletion  by  the  administration  of 
tartar  emetic ;  and,  under  proper  restrictions,  the  remedy  is  no  less 
valuable  in  early  life.  Given  in  doses  of  one-eighth  of  a  grain  every 
ten  minutes  till  vomiting  is  produced  in  the  case  of  a  child  of  two  years 
old,  and  continued  every  hour  or  two  hours  afterwards  for  a  period  of 
twenty-four  or  thirty-six  hours,  it  subdues  the  fever  and  abates  the 
dyspnoea  in  a  most  remarkable  manner ;  often  rendering  a  repetition 
of  depletion  unnecessary,  and  sometimes  speedily  removing  all  signs  of 
the  disease.  It  is  not  safe,, however,1  in  the  great  majority  of  cases,  to 
place  our  dependence  entirely  on  the  administration  of  antimony.  In 
cases  of  secondary  pneumonia,  especially  if  the  affection  of  the  paren- 
chyma of  the  lungs  were  preceded  by  well-marked  bronchitic  symptoms, 
antimony  may  sometimes  be  given  at  once  without  having  recourse  to  the 
abstraction  of  blood  previously ;  but,  in  pure  idiopathic  pneumonia, 
depletion  either  general  or  local  ought  almost  always  to  precede  its  use. 
When  antimony  does  good,  it  generally  gives  an  earnest  of  that  good 
within  a  few  hours  from  its  first  administration  ;  and  the  production  of 
some  sensible  effect,  such  as  vomiting  or  very  decided  nausea,  has 
appeared  to  me  to  be  a  condition  of  its  utility :  unlike  what  we  observe 
in  the  adult,  in  whom  the  good  results  which  it  produces  are  sometimes 
independent  of  any  appreciable  influence  on  the  general  condition  of 
the  patient.  When  complete  tolerance  of  the  medicine  has  been 
established,  our  subsequent  conduct  must  be  determined  by  the  results 
of  auscultation.  Should  that  inform  us  that  the  physical  condition  of 
the  lung  has  greatly  improved,  as  well  as  the  general  state  of  the 
patient,  the  use  of  the  remedy  may  be  persevered  in  at  somewhat  longer 
intervals.  If  the  signs  of  inflammation  be  advancing,  and  have 
become  perceptible  in  portions  of.  lung  previously  free  from  dis- 
ease, mercury  must  be  employed,  which  may  be  combined  with  small 
doses  of  antimony,  while  large  doses  of  that  remedy  may  still  be  given 
to  combat  any  sudden  increase  of  fever  or  dyspnoea  that  may  chance 
to  supervene.  If,  notwithstanding  a  manifest  diminution  of  the  fever 
and  reduction  of  the  dyspnoea,  bronchial  breathing  should  have 
become  distinctly  audible,  mercurials  must  at  once  be  substituted  for 
the  antimony ;  and  the  existence  in  any  case  of  extensive  or  well-marked 
bronchial  respiration  should  be  regarded  as  of  itself  contraindicating 
the  antimonial  plan  of  treatment.  It  is  not  my  intention  to  say,  that 
after  the  supervention  of  bronchial  respiration  antimony  ought  never  to 
be  given,  but  only  that  it  should  not  be  employed  except  in  small  doses, 
and  in  combination  with  other  remedies. 

In  cases  where  the  symptoms  do  not  set  in  with  such  violence  as  to 
indicate  the  necessity  for  very  large  doses  of  antimony,  or  in  which 
the  disease  has  passed  that  stage  where  antimony  so  given  is  likely  to 
be  beneficial,  mercurials  may  be  used  with  great  advantage.  In  cases 
of  the  former  kind,  from  two-thirds  of  a  grain  to  a  grain  of  calomel, 
combined  with  two  or  three  grains  of  James's  powder,  may  be  given 
every  six  hours  to  a  child  two  years  old.     If  the  case  be  of  a  graver 


202  EMPLOYMENT   OF   MERCURIALS — DIET — STIMULANTS. 

kind,  and  bronchial  breathing  have  become  perceptible,  notwithstanding 
depletion  and  the  administration  of  tartar  emetic,  the  calomel  must  be 
given  more  frequently, — as  every  four  or  three  hours,  combined  with 
small  doses  of  Dover's  powder  and  tartar  emetic,  if  the  child  be  not  so 
depressed  as  to  render  the  use  of  the  latter  medicine  inexpedient. 
Sometimes  the  combination  of  antimony  with  the  mercurial  is  at  first 
well  borne,  but  afterwards  it  becomes  desirable  to  discontinue  it  on 
account  of  the  sickness  that  it  produces,  or  on  account  of  the  debility  of 
the  patient.  The  diarrhoea  which  the  calomel  excites  may  usually  be 
checked  by  increasing  the  dose  of  the  Dover's  powder.  There  are 
some  troublesome  cases,  however,  in  which  the  stomach  or  bowels  are 
so  irritable  that  scarcely  any  medicine  can  be  borne  ;  and  in  them,  as 
well  as  in  cases  of  neglected  pneumonia  in  which  the  proper  time  for 
active  treatment  has  been  allowed  to  pass  by,  and  the  child  has  become 
exhausted,  while  a  large  extent  of  lung  is  impervious  to  air,  much 
benefit  sometimes  follows  the  persevering  use  of  mercurial  inunction. 
In  infants  and  children  under  five  years  of  age,  the  gums  hardly  ever 
become  affected  by  mercury,  even  though  most  energetically  employed  ; 
and  it  has  never  yet  occurred  to  me  to  meet  with  an  instance  of  profuse 
salivation,  or  dangerous  ulceration  of  the  gums.  Such  accidents,  how- 
ever, do  now  and  then  occur,  and  have  been  known  to  terminate  in 
fatal  gangrene  of  the  cheek,  or  necrosis  of  the  jaw.  On  this  account, 
therefore,  you  must  watch  the  condition  of  the  gums'  in  infants  and 
children  to  whom  you  are  administering  mercury,  just  as  you  would  do 
in  the  case  of  the  adult,  and  diminish  or  discontinue  the  remedy  on  the 
first  indication  of  their  being  affected. 

The  diet  of  children  in  the  early  stages  of  pneumonia  should  be  most 
sparing ;  and  infants  not  weaned  should  have  some  less  nutritious  food 
than  the  mother's  milk,  which  their  thirst  will  otherwise  lead  them  to 
take  more  abundantly  even  than  when  they  are  well.  If  the  pneumonia 
be  severe,  it  is  better  to  give  even  the  mother's  milk  with  a  spoon, 
rather  than  to  allow  the  infant  to  suck,  since  the  very  act  of  sucking 
is  injurious,  and  taxes  to  the  utmost  the  respiratory  function,  the  organs 
of  which  it  is  desirable  to  keep  in  as  unexcited  a  state  as  possible. 

But  though  the  treatment  of  inflammation  of  the  lungs  requires  a 
most  strict  antiphlogistic  regimen  in  the  early  stages  of  the  disease, 
yet  in  many  cases  there  arrives  a  period  in  which  a  spare  diet  is  no 
longer  suitable, — in  which  your  main  efforts  must  be  directed  to  support 
the  constitutional  powers,  rather  than  to  subdue  the  local  inflammation. 
If  you  forget  this,  it  may  happen  to  you  to  overcome  the  mischief  in 
the  chest,  but  to  lose  your  patient  with  head  symptoms,  brought  on' by 
carrying  too  far,  or  continuing  too  long,  the  very  treatment  which, 
within  proper  limits,  was  most  salutary.  No  point  in  the  management 
of  the  disease  is  more  difficult  than  the  seizing  the  exact  moment  when 
the  employment  of  stimulants  becomes  necessary ;  and  no  general  rule 
can  be  laid  down  for  regulating  their  use.  If,  however,  the  patient 
were  beginning  to  be  much  purged,  if  the  respiration  were  growing 
more  laboured  and  irregular,  though  diminished  in  frequency,  and  if  the 
pulse  were  becoming  more  frequent,  and  above  all  smaller  and  smaller, 
it  is  high  time  to  resort  to  their  use.     Wine  is  as  indispensable  in  such 


CEDEMA   OF   THE   LUNGS.  203 

cases  in  the  pneumonia  of  the  child  as  in  that  of  the  adult ;  and  it  may 
be  necessary  to  give  it  even  to  infants  at  the  breast.  Ammonia  may 
also  be  advantageously  administered  in  this  stage  of  the  disease,  either 
in  a  mixture  with  the  decoction  of  senega,1  or  dissolved  in  milk,  which 
conceals  its  disagreeable  pungency  better  than  any  other  vehicle.  If 
diarrhoea  do  not  exist,  strong  beef-tea  or  veal  broth  is  the  best  form  in 
which  nutriment  can  be  given  ;  but  if  the  bowels  be  relaxed,  arrow- 
root, or  the  decoction  blayiche2  of  the  French  Hospitals,  should  be  sub- 
stituted for  it. 

In  conclusion,  it  may  be  well  to  offer  a  caution  with  reference  to  the 
employment  of  blisters, — a  measure  to  which  we  often  have  recourse 
with  advantage  during  the  resolution  of  pneumonia  in  the  adult,  but 
which,  as  a  general  rule,  is  not  advisable  in  young  children  whose  lungs 
have  been  solidified  by  the  disease.  Stimulating  liniments3  may  be 
employed  with  advantage;  they  produce  very  evident  good,  and  are 
unattended  by  the  risk  that  always  accompanies  making  a  breach  of 
the  surface  in  a  young  child  exhausted  by  previous  illness.  The  risk 
of  such  sores  taking  on  an  unhealthy  character,  appears  to  be  greater 
after  inflammation  of  the  lungs  than  after  almost  any  other  disease ; 
and  it  may  be  added,  that  the  risk  is  still  greater  in  those  cases  of 
secondary  pneumonia  that  supervene  on  measles. 


LECTURE    X  VIII. 

(Edema  of  tiie  Lungs — occasionally  comes  on  in  the  course  of  scarlatinal  dropsy — 
severity  of  the  symptoms,  and  their  sudden  accession — Difference  between  the  cha- 
racters of  cedematous  and  hepatized  lung — treatment — importance  of  venesection 
— occasional  exceptions  to  its  use. 

Gangrene  of  the  Lung — Case  illustrative  of  the  disease — is  not  the  result  of  mere 
intensity  of  inflammation — unattended  by  any  pathognomonic  symptom. 

Pleurisy — its  rarity  in  childhood  as  an  acute  uncomplicated  idiopathic  affection — 
its  symptoms  and  morbid  appearances  similar  to  those  observed  in  the  adult— it 
occasionally  stimulates  other  diseases,  as  affections  of  the  head  and  of  the  abdomen 
— Evidences  of  auscultation  less  conclusive  than  in  the  adult,  and  why. 

Treatment — importance  of  early  adoption  of  active  measures — principles  of  treatment 
same  as  in  the  adult. 

Chronic  pleurisy — rarely  idiopathic — occurs  oftener  in  connection  with  dropsy  after 
scarlatina — its  symptoms  frequently  obscure. 

Before  we  proceed  to  the  examination  of  some  other  forms  of  inflam- 
matory disease  of  the  respiratory  organs,  it  may  be  convenient  to 
notice  two  conditions  of  the  pulmonary  tissue,  which,  though  not  the 
direct  results  of  inflammation,  yet  are  closely  connected  with  it.  One 
of  these  conditions  is  acute  oedema  of  the  lung,  the  other  is  gangrene 
of  its  substance. 

It  is  unnecessary  to  occupy  your  time  with  any  detailed  account  of 
that  anasarcous  state  of  the  lungs  which  is  sometimes   met  with  in 

1  See  Formula  No.  12,  p.  190.        2  See  Note,  p.  45.        3  See  Formula  No.  11,  p.  190. 


204  (EDEMA   OP   THE  LUNGS. 

connection  with  general  dropsy  of  long  standing,  or  with  some  old 
disease  of  the  heart  and  great  vessels.  In  such  cases,  which  are  very 
rare  in  childhood,  the  oedema  of  the  lungs  is  a  secondary  affection,  and 
has  very  little  share  in  producing  the  patient's  death.  But  it  occa- 
sionally happens  that  children  are  attacked  with  intense  dyspnoea,  and 
other  symptoms  of  disorder  of  the  respiratory  organs,  which  terminate 
rapidly  in  death  ;  while  it  is  discovered,  on  an  examination  of  the  body, 
that  the. thoracic  viscera  generally  are  free  from  disease,  but  that  the 
cellular  tissue  of  the  lungs  is  loaded  with  serous  fluid.  Laennec1  refers 
to  such  an  accident  as  probably  accounting  for  the  occasional  sudden 
supervention  of  extreme  dyspnoea  in  children  recovering  from  measles ; 
but  a  recent  French  writer,  M.  Legendre,2  is,  to  the  best  of  my  know- 
ledge, the  first  person  who  has  clearly  proved  the  connection  between 
the  symptoms  observed  during  life,  and  the  state  of  extreme  oedema  of 
the  pulmonary  tissue  after  death. 

This  oedema  of  the  lungs,  though  it  sometimes  destroys  life  very  speed- 
ily, is  seldom,  if  ever,  a  purely  idiopathic  affection,  but  occurs  generally 
as  one  of  the  complications  of  that  acute  anasarca  which  not  infrequently 
succeeds  to  scarlatina ;  and  even  then  it  is  not  of  common  occurrence. 
M.  Legendre  records  only  four  cases,  all  of  which  were  observed  in 
children  who  were  suffering  from  anasarca  after  scarlatina ;  and  three 
fatal  instances  of  it  have  come  under  my  own  notice,  in  all  of  which  it 
supervened  during  scarlatinal  dropsy.  In  two  of  these  cases  it  came  on 
while  the  children  were  labouring  under  a  great  degree  of  anasarca ;  on 
the  third  occasion  the  dropsy  had  greatly  abated  before  the  thoracic 
symptoms  appeared.  Indications  of  slight  mischief  in  the  chest,  such 
as  frequent  dry  cough,  some  degree  of  dyspnoea,  with  rhonchus  and 
sibilus,  or  scanty  crepitation,  preceded  the  more  serious  symptoms  for 
two  or  three  days.  The  patient,  in  short,  had  seemed  to  be  suffering 
from  a  bronchitis  of  moderate  intensity,  when  suddenly  extreme  difficulty 
of  respiration  supervened,  attended  with  very  hurried  breathing,  ortho- 
pnoea,  and  most  tumultuous  and  violent  action  of  the  heart,  though  with 
a  feeble  pulse.  The  cough  continued,  being  still  short,  and  quite  unac- 
companied by  expectoration.  Auscultation  under  such  circumstances 
does  not  seem  to  give  account  of  mischief  sufficiently  serious  to  explain 
the  alarming  nature  of  the  symptoms.  It  may  be  thought  that  air 
enters  the  lungs  less  freely  than  it  should  do ;  but  the  crepitation  heard 
is  scanty,  and  neither  bronchial  respiration  nor  diminished  resonance 
on  percussion  of  the  chest  is  perceptible.  Nevertheless,  if  relief  be  not 
soon  afforded,  the  child's  sufferings  in  a  few  hours  amount  to  perfect 
agony ;  the  difficulty  of  respiration  and  the  tumultuous  action  of  the 
heart  continuing ;  the  lips  and  face  becoming  perfectly  livid,  but  the 
intellect  remaining  clear,  and  the  child  complaining  of  great  distress ; 
referred  to  the  heart  or  epigastrium ;  till  at  length  death  takes  place 
suddenly,  which  it  sometimes  does  within  twenty-four  hours  from  the 
appearance  of  these  alarming  symptoms.  At  other  times  the  approach 
of  the  disease  is  more  gradual,  the  dyspnoea  being  augmented  in  parox- 

1  On   the  Diseases  of  the  Chest,   translated  by  Dr.    Forbes,  4th  edition,  p.   164. 
London,  1834. 
8  ltecherches  sur  quelques  Maladies  de  l'Enfance,  8vo.  p.  324-352.     Paris,  1846. 


CHARACTERS   OF   (EDEMATOUS   LUNG — TREATMENT.  205 

ysms,  but  on  the  whole  increasing  with  the  increase  of  the  general 
anasarca,  and  proving  fatal  in  the  course  of  five  or  six  days. 

On  examining  after  death  the  bodies  of  children  who  have  died  of  this 
acute  oedema  of  the  lungs,  a  little  transparent  serum  is  usually  found  in 
the  chest,  and  a  few  deposits  of  lymph  on  the  surface  of  the  lung  some- 
times betoken  the  existence  of  slight  inflammation  of  the  pleura.  The 
lungs  themselves  are  of  a  deep  red  colour,  firm,  and  destitute  of  air 
through  a  great  extent  of  their  substance,  not  breaking  down  so  easily 
as  lung  in  a  state  of  true  hepatization  would  do,  but  giving  exit  when 
cut  into  to  a  most  abundant  quantity  of  reddish  serum,  mixed  with  very 
few  air-bubbles.  The  right  auricle  and  ventricle  are  enormously  dis- 
tended with  coagulated  blood, — a  token  of  the  difficulty  with  which  the 
heart  has  discharged  the  functions  to  the  performance  of  which  it  at 
length  became  wholly  unequal.  To  this  description  two  importanfopar- 
ticulars  may  be  added  from  the  account  given  by  M.  Legendre  :  the  one, 
that  punctures  of  the  lung  will  allow  the  fluid  to  drain  out,  and  thus 
restore  to  the  organ  much  of  its  previous  flaccidity ;  the  other,  that  by 
the  insufflation  of  air,  the  tissue  of  the  lung  may  be  made  to  resume  its 
natural  suppleness  and  its  light  colour,  and  once  more  to  crepitate  as  in 
a  state  of  health.  From  these  facts  M.  Legendre  concludes,  and  his 
opinion  is,  I  doubt  not,  quite  correct,  that  the  cellular  tissue  of  the  lung 
is  in  these  cases  the  chief  seat  of  the  serous  effusion,  and  that  dyspnoea 
is  produced  by  the  consequent  compression  of  the  air-cells. 

In  the  treatment  of  any  case  in  which  the  symptoms  just  enumerated 
come  on,  free  venesection  affords  most  remarkable  and  almost  immedi- 
ate relief,  and,  whenever  it  is  practicable,  is  much  to  be  preferred  to  the 
most  abundant  depletion  by  means  of  leeches  applied  to  the  neighbourhood 
of  the  heart.  After  depletion,  large  doses  of  tartar  emetic  should  be 
given,  since  there  is  no  other  remedy  that  so  speedily  or  effectually 
reduces  the  urgent  dyspnoea.  In  the  subsequent  management  of  the 
case  just  such  remedies  are  required  as  would  be  best  calculated  to 
relieve  the  general  dropsy ;  and  as  that  decreases,  the  oedema  of  the 
lungs  will  likewise  diminish  and  disappear. 

Sometimes  you  may  meet  with  cases  in  which  the  coldness  of  the 
extremities,  and  the  great  lividity  of  the  surface,  seem  to  forbid  deple- 
tion. Such  an  instance  I  once  saw  :  the  patient  was  a  girl  about  nine 
years  old,  in  whom  all  the  symptoms  had  come  on  very  suddenly  a  few 
hours  before  I  saw  her,  and  who  appeared  almost  dying  at  the  time  of 
my  visit.  I  applied  a  large  mustard-poultice  over  her  chest,  gave  her 
a  draught  containing  a  large  dose  of  nitrous  ether,  and  repeated  it 
every  two  hours.  In  the  course  of  eight  or  ten  hours,  she  was  suffi- 
ciently rallied  to  bear  venesection,  which  was  followed  by  a  most 
marked  amendment,  and  in  a  few  days  her  recovery  was  complete. 

My  experience  of  gangrene  of  the  lung  in  childhood  is  still  more 
limited  than  that  of  the  acute  oedema  of  its  tissue,  for  only  one  case  of 
it  has  come  under  my  notice.  The  particulars  of  it,  however,  may  be 
worth  relating,  since  they  illustrate  very  well  the  symptoms  which  the 
disease  usually  presents,  and  the  circumstances  under  which  it  gene- 
rally occurs. 

A  little  girl,  three  years  old,  the  child  of  healthy  parents,  who  had 


206  GANGRENE   OF   THE  LUNG. 

previously  had  good  health,  with  the  exception  of  a  severe  attack  of 
inflammation  of  the  lungs  when  two  years  old,  began  to  droop  in  health, 
to  cough,  and  to  have  shortness  of  breath,  on  the  11th  of  February, 
1843.  No  treatment  was  adopted  until  the  child  was  brought  to  me 
on  the  15th.  Her  breathing  was  then  more  oppressed,  her  general 
condition  more  cast  down,  and  her  strength  more  reduced  than  is  usual 
in  so  short  a  time  from  the  commencement  of  an  attack  of  pneumo- 
nia, which  had  not  set  in  with  very  severe  symptoms.  Four  leeches 
were  applied  beneath  the  right  scapula,  and  half  grain  doses  of  calo- 
mel and  Dover's  powder  were  given  every  three  hours.  Slight  relief 
succeeded  to  the  bleeding,  but  this  was  of  but  short  duration ;  and  the 
child  did  not  seem  to  be  either  better  or  seriously  worse  until  the  19th, 
when  she  appeared  to  be  losing  strength.  The  mercury  was  now  dis- 
continued, and  ammonia  and  nourishing  diet  were  freely  given.  On  the 
20th,  the  gums  both  of  the  upper  and  lower  jaw  began  to  swell ;  by 
the  next  day  they  were  ulcerated  ;  the  breath  became  very  foetid,  and 
a  discoloured,  stinking  fluid,  ran  from  the  mouth.  The  thoracic  symp- 
toms continued  much  the  same,  not  at  all  increasing  in  intensity,  and 
the  cough  growing  looser  than  before ;  but  the  child  became  paler  and 
more  exsanguine,  and  continued  to  lose  power.  The  ulceration  of  the 
gums  extended  to  the  fold  of  the  lower  lip,  and  three  of  the  incisor 
teeth  fell  out  before  the  disease  was  finally  checked,  on  Feb.  26th,  by 
the  application  of  the  pure  nitric  acid.  The  child  did  not  appear  to 
suffer  pain,  but  was  very  restless,  and  continually  harassed  by  efforts 
to  vomit,  during  which  she  rejected  nothing  but  an  offensive  mucus. — 
She  was  extremely  indisposed  to  take  either  wine  or  any  nourishment 
for  four  days  before  her  death,  which  took  place  apparently  from 
exhaustion  on  the  1st  of  March,  nineteen  days  after  the  commencement 
of  her  illness. 

On  an  examination  of  the  body  after  death,  the  left  lung  was  found 
perfectly  healthy,  with  the  exception  of  some  emphysema  of  its  upper, 
and  considerable  congestion  of  its  lower  lobe. 

The  right  lung,  which  consisted  of  only  two  lobes,  was  universally 
solid  and  non-crepitant,  with  the  exception  of  about  a  fourth  of  the 
upper  and  inner  edge  of  the  upper  lobe  which  was  emphysematous. 
The  two  lobes  were  connected  together  by  a  layer  of  yellow  lymph. — 
The  exterior  of  the  lung  generally  was  of  a  dark  greyish  red  colour, 
with  irregular  patches  of  yellow  deposit  beneath  the  pleura,  some  of 
which  were  nearly  half  an  inch  in  length  and  a  quarter  in  breadth ; 
besides  which  many  small  purulent  deposits  were  contained  within  the 
pulmonary  veicles,  as  in  vesicular  bronchitis.  The  upper  part  of  the 
upper  lobe,  and  a  small  portion  near  the  diaphragmatic  surface  of  the 
lower  lobe,  felt  soft  and  boggy  to  the  touch.  On  cutting  into  the 
upper  lobe,  a  cavity  was  opened  as  large  as  a  hen's  egg,  very  irregular 
in  form,  intersected  in  various  directions  by  the  tubes  and  vessels  that 
crossed  it ;  from  which,  as  well  as  from  the  walls  of  the  cavity,  portions 
of  lung  hung  in  shreds.  The  cavity  contained  a  small  quantity  of 
dirty,  greyish  yellow,  putrilage,  which  exhaled  a  most  foetid  odour.  The 
substance  of  the  lung  in  the  immediate  neighbourhood  was  in  a  far 
advanced  stage  of  purulent  infiltration,  and  other  parts  of  the    lobe 


GANGRENE   OF   THE   LUNG.  207 

were  in  an  earlier  stage  of  the  same  condition  ;  besides  which,  small  col- 
lections of  puriform  fluid,  not  bigger  than  a  split-pea,  were  found  in 
various  parts  of  its  substance.  The  state  of  the  lower  lobe  on  the  whole 
resembled  that  of  the  upper,  but  the  cavity  in  its  lower  lobe  was  not 
larger  than  a  marble,  and  contained  a  small  quantity  of  yellow  pus  of 
a  less  foetid  character  than  in  the  upper  lobe.  The  bronchial  glands 
were  swollen,  soft,  of  a  homogeneous  aspect,  and  a  grey  colour ;  but 
neither  in  them,  nor  in  either  lung,  nor  in  any  organ  of  the  body,  was 
there  the  least  trace  of  tubercular  deposit. 

Although  there  was  in  this  instance  a  larger  amount  of  inflammatory 
disorganization  of  the  lung  than  is  usually  met  with  in  connection  with 
gangrene  of  its  substance,  yet  the  symptoms  noticed  during  the  patient's 
life-time  were  precisely  such  as  are  generally  observed  in  cases  of  this 
description.  The  child  was  attacked  with  symptoms  of  pneumonia 
which,  however,  were  far  from  being  severe  ;  but  nevertheless,  by  the 
fifth  day  from  their  commencement,  the  greater  part  of  the  right  lung 
had  become  impervious  to  air,  and  percussion  over  the  right  side  of  the 
chest,  on  the  15th  of  February,  yielded  an  almost  entirely  dull  sound. 
Even  then  the  child's  strength  seemed  much  reduced,  and  in  the  course 
of  a  few  days  more  she  sank  into  a  state  of  great  weakness.  Through- 
out the  whole  course  of  the  disease,  there  was  the  same  absence  of 
striking  indications  of  the  extent  to  which  the  respiratory  organs  had 
suffered,  and  this  even  after  a  large  portion  of  the  lung  was  completely 
disorganized.  The  most  remarkable  phenomena  were  those  which 
betokened  the  general  loss  of  power  in  the  system,  while  the  apearance 
of  gangrenous  ulceration  about  the  gums  tended  to  prove  the  correctness 
of  the  opinion  which  refers  the  disease  to  some  peculiar  alteration  of 
the  circulating  fluid,  rather  than  to  the  violence  of  the  inflammatory 
action.  Another  circumstance  which  tends  to  support  this  opinion  is, 
that  gangrene  of  the  lung  much  more  frequently  supervenes  on  the 
pneumonia  that  comes  on  in  the  course  of  the  exanthematous  fevers, 
than  on  idiopathic  inflammation  of  the  lungs.  The  disease,  too,  occurs 
far  more  rarely  in  children  who  are  well  fed,  and  who  live  in  pure  air,  than 
in  those  who  are  surrounded  by  unfavourable  hygienic  conditions.  Hence 
it  results  that  this,  as  well  as  other  forms  of  gangrene,  are  met  with  in 
the  Children's  Hospital  at  Paris  with  far  greater  frequency  than  elsewhere, 
and  that  they  sometimes  show  a  tendency  to  become  epidemic  in  that 
institution. 

There  is  no  symptom  that  can  be  mentioned  as  of  constant  occurrence 
in  gangrene  of  the  lung  in  children,  and  as  pathognomonic  of  the 
disease.  That  peculiar  fcetor  of  the  breath  on  which  so  much  reliance 
is  placed  in  cases  of  gangrene  of  the  lung  in  the  adult,  sometimes  loses 
its  value  in  the  child,  as  it  did  in  the  case  just  related,  by  the  coexistence 
with  it  of  gangrene  of  the  mouth.  It  happens,  too,  not  infrequently, 
that  the  characteristic  odour  of  the  breath  is  altogether  absent  in  cases 
of  gangrene  of  the  lung, — a  circumstance  for  which  it  is  not  easy  to 
account;  though  of  the  fact  there  can  be  no  doubt,  since  it  rests  on  the 
authority  of  MM.  Rilliet  and  Barthez. 

Should  you  meet  with  any  case  in  which  you  apprehend  that  this 
condition  of  the  lung  is  present,  you  would  adopt  a  tonic  and  stimulant 


208  ACUTE   PLEURISY. 

plan  of  treatment,  as  affording  the  only  chance,  and  that  a  very 
slender  one,  of  saving  the  patient's  life.  Dr.  Stokes's  suggestion,  too, 
for  the  administration  of  chlorine,  should  not  be  forgotten,  since,  if  the 
remedy  did  nothing  else,  it  might  diminish  that  foetor  of  the  breath 
which  is  a  source  of  very  great  suffering  to  the  patient. 

We  pass  now  from  the  examination  of  the  inflammatory  affections  of 
the  substance  of  the  lung,  to  the  study  of  those  to  which  its  investing 
membrane  is  liable.  It  will  not,  however,  be  necessary  to  occupy  very 
much  of  your  time  with  the  subject  of  pleurisy  in  childhood,  since, 
though  it  is  a  very  important  disease,  yet  neither  its  symptoms,  course, 
nor  treatment,  undergo  such  modifications  from  the  early  age  of  the 
patient  as  we  have  observed  in  some  other  of  those  affections  which  we 
have  already  passed  in  review.  Some  writers  on  the  diseases  of  chil- 
dren, indeed,  have  left  pleurisy  altogether  unnoticed,  on  account  of  its 
supposed  extreme  rarity  in  early  life  ;  but  this  opinion  is  certainly 
erroneous,  so  far  as  regards  that  secondary  pleurisy  which  comes  on 
in  the  course  of  pneumonia,  and  which  is  almost,  if  not  quite,  as  fre- 
quent in  childhood  as  in  adult  age.  Acute  idiopathic  pleurisy,  uncon- 
nected with  pneumonia,  or  in  which  the  inflammation  of  the  lung  bears 
but  a  very  small  proportion  to  that  of  the  pleura,  is  certainly  an 
uncommon  affection  during  the  first  years  of  childhood,  and  as  a  cause 
of  death,  its  rarity  is  extreme.  It  appears  from  the  Reports  of  the 
Registrar-General,  that  of  202  fatal  cases  of  pleurisy  that  occurred  in 
London  in  the  years  1842  and  1845,  only  14,  or  6.4  per  cent,  took  place 
in  children  under  five  years  old,  while  you  will  not  have  forgotten  that 
63.2  per  cent,  of  all  fatal  cases  of  pneumonia  are  alleged  on  the  same 
authority  to  have  befallen  children  aged  less  than  five  years.  Acute 
idiopathic  pleurisy  has  run  a  fatal  course  in  children  under  five  years 
of  age  only  on  five  occasions  which  I  have  had  the  opportunity  of 
observing, — a  result  that  has  seemed  to  be  due  at  least  as  much  to  the 
rarity  of  the  disease  as  to  its  being  seldom  fatal.  After  five  years 
of  age,  however,  the  frequency  of  pleurisy  manifestly  increases,  and 
during  the  later  years  of  childhood  it  is  little,  if  at  all  less  frequent, 
than  in  the  adult. 

In  fatal  cases  of  pleurisy  in  childhood,  the  appearances  found  after 
death  are  precisely  the  same  as  are  met  with  in  the  adult.  Adhesions 
between  the  costal  and  pulmonary  pleura,  and  between  the  different 
lobes  of  one  or  other  lung,  associated  sometimes  with  very  intense  red- 
ness of  parts  of  the  membrane,  are  hardly  ever  wanting,  and  in  con- 
nection with  them  a  small  quantity  of  transparent  serum,  often  of  a 
reddish  tint,  is  sometimes  effused  into  the  cavity  of  the  chest.  In  other 
cases  the  effused  matters  are  entirely  solid,  and  both  the  surface  of  the 
lung  and  the  interior  of  the  thorax  are  coated  with  a  distinct  investment 
of  lymph ;  or,  in  addition  to  the  deposit  of  lymph  on  the  lung,  fluid  is 
poured  out  into  the  chest, — no  longer  transparent  serum,  but  either  a 
sero-purulent  fluid,  in  which  flakes  of  lymph  are  floating,  or,  more 
rarely,  healthy  pus.  The  most  frequent  complication  of  pleurisy  is 
with  inflammation  of  the  lungs ;  besides  which  it  occasionally  happens, 
when  the  left  pleura  has  been  the  seat  of  inflammation,  that  the  disease 
extends  from  it  to  the  pericardium,  which  on  two  such  occasions  I  have 


SYMPTOMS   OF   ACUTE   PLEURISY.  209 

found  lined  with  lymph,  partially  adherent  to  the  heart,  and  containing 
a  sero-purulent  fluid. 

The  main  symptoms  that  attend  the  disease,  as  well  as  the  physical 
signs  of  its  existence,  are  the  same  at  all  ages.  There  are,  however, 
some  circumstances  peculiar  to  early  life,  which,  unless  you  are  on 
your  guard,  may  serve  to  obscure  the  real  nature  of  the  affection.  The 
history  of  a  case  of  acute  pleurisy  in  childhood  is  generally  something 
to  this  effect: — A  child  previously  in  perfect  health,  is  suddenly 
attacked  with  pain  referred  to  the  chest  or  upper  part  of  the  abdomen, 
so  severe  as  to  occasion  it  to  cry  aloud ;  perhaps  attended  at  first 
with  vomiting  of  a  greenish  fluid,  accompanied  with  fever,  a  rapid 
pulse,  and  hurried  respiration,  interrupted  by  frequent  short  cough, 
which  evidently  occasions  pain,  and  wThich  the  child  labours,  though  in 
vain,  to  suppress.  After  a  few  hours  the  severity  of  the  pain  subsides  ; 
but  the  fever,  hurried  respiration,  and  cough,  continue,  and  the  child, 
though  usually  it  looks  heavy  and  seems  drowsy,  yet  becomes  extremely 
restless  at  intervals, — cries  and  struggles  as  if  in  pain,  and  violently 
resists  any  attempt  to  alter  its  position,  since  every  movement  brings 
on  an  exacerbation  of  its  sufferings.  The  posture  which  it  selects 
varies  much  :  sometimes  its  breath  seems  disturbed  in  any  other  than 
an  upright  position ;  at  other  times  it  lies  on  its  back,  or  on  one  side ; 
but,  whatever  be  the  posture,  any  alteration  of  it  appears  to  cause  much 
distress,  and  is  sure  to  be  resisted  by  the  patient. 

The  probabilities  are,  that,  if  you  auscultate  the  chest  of  a  child 
in  whom  these  symptoms  exist,  you  will  hear  good  breathing  through 
the  whole  of  one  lung.  On  the  other  side,  the  air  will  be  most  likely 
found  to  enter  less  freely,  though  unaccompanied  by  any  moist  sound, 
perhaps  unattended  with  any  morbid  sound  at  all ;  or,  a  rough  sound 
like  a  rhonchus  may  be  audible  on  this  side,  and  for  this  you  may  very 
likely  at  first  take  it,  though  with  more  attention  it  will  be  discovered 
to  be  a  friction  sound.  A  day  or  two  later  you  will  probably  detect  a 
sound  like  that  of  bronchial  breathing,  as  you  pass  your  ear  from  above 
downwards  along  the  posterior  part  of  the  chest,  while  the  friction 
sound  will  have  disappeared ;  and  still  lower  there  will  be  an  utter 
absence  of  all  sound.  The  walls  of  this  side  of  the  chest,  if  their 
tenderness  do  not  prevent  your  trying  percussion,  will  yield  a  much 
less  resonant  sound  than  usual ;  while,  at  the  same  time,  a  distinct 
sense  of  solidity  will  be  communicated  to  the  finger. 

I  need  hardly  pursue  the  detail  of  other  symptoms  which  are  the 
necessary  result  of  pleurisy  whatever  be  the  age  of  the  person  in  whom 
it  occurs.  The  diminished  mobility  of  the  affected  side,  the  displace- 
ment of  the  heart,  the  bulging  of  the  intercostal  spaces,  and  the  enlarge- 
ment of  the  chest  on  the  diseased  side,  are  phenomena  that  take  place 
under  the  influence  of  the  same  causes  at  every  age,  though  their  occur- 
rence is  less  frequent  in  childhood  than  in  adult  age,  since  the  effusion 
of  fluid  is  usually  more  scanty.  The  course  of  the  disease,  whether 
towards  recovery  or  to  a  fatal  issue,  presents  nothing  remarkable  in 
childhood ;  but  it  is  chiefly  at  the  commencement  of  the  disease  that 
you  are  likely  to  mistake  its  nature. 

The  symptoms  by  which  an  attack  of  acute  pleurisy  is  ushered  in 

14 


210  DIAGNOSIS   OF  PLEURISY. 

point  sometimes   rather  to  the  head  than  to  the  chest.     The  child  is 
seized  with  vomiting,  attended  with  fever   and  intense  headache :  it 
either  cries  aloud,  or  is  delirious  at  night,  or  screams  much  in  its  sleep, 
and,  when  morning  comes,  complains  much  of  its  head,  but  denies 
having  any  pain  whatever  in  its  chest,  while  the  short  cough  and  the 
hurried  breathing  may  be  thought  to  be  merely  the  result  of  the  cere- 
bral disturbance.     Sometimes,  too,  the  cough  is  altogether  absent,  and 
the  acceleration  of  the  breathing  so  slight  as  not  to  suggest  the  idea 
that  serious  mischief  is  going  on  in  the  chest.     Under  the  impression 
that  the  child  is  suffering  from  cerebral  disease,  auscultation  is  omitted, 
or  at  least  practised  hastily  and  superficially,  and  consequently  serves 
but  to  confirm  the  erroneous  diagnosis.     It  often  happens,  indeed,  that 
in  these  cases  no  friction  sound  is  perceptible,  and  that  you  have  no 
other  indication  to  guide  you  aright  besides  the  feebleness  of  the  respi- 
ratory murmur  on  the  affected  side.     The  child,  too,  fearful  of  taking 
a  deep  inspiration,  fills  neither  lung  completely,  so  that  the  information 
usually  gained  by  comparison  of  the  breathing  in  one  lung  with  that  of 
the  other  is  in  great  measure  lost.     Still,  the  presence  of  feeble  respi- 
ratory murmur,  at  the  lower  part  of  one  lung,  when  coupled  with  the 
sudden  access  of  acute  febrile  symptoms  in  a  previously  healthy  child, 
points  almost  invariably  to  the  existence  of  acute  pleurisy ;  while  a 
careful  consideration   of  the   patient's  history  and  general   condition 
will,  even  irrespective  of  the  results  of  auscultation,  go  far  towards  pre- 
venting you  from  falling  into  error.     The  onset  of  the  illness  has  been 
far  too  acute,  attended  with  far  too  much  febrile  disturbance,  for  a  case 
of  tubercular  hydrocephalus,  while  many  of  the  signs  of  cerebral  mis- 
chief which  might  be  expected  in  a  case  of  simple  encephalitis  have  not 
presented  themselves.     The  heat  of  head  is  not  greater  than  that  of 
the  rest  of  the  surface ;  the  cries  with  which  the  disease  set  in  have  not 
ended  in  coma.     It  happens  but  seldom  that  convulsions  mark  the  com- 
mencement of  the  disease ;  but,  if  they  had  occurred  at  the  onset,  they 
have  not  since  returned:  neither  twitching  of  the  muscles,  nor  strabismus, 
nor  retraction  of  the  head,  is  present;  and,  though  the  child  may  cry 
(as  children  when  ill  and  fretful  often  do)  at  the  curtain  being  undrawn 
and  the  candle  brought  near  it,  yet  there  is  no  real  intolerance  of  light, 
while,  in  spite  of  its  fretfulness,  the  intelligence  is  not  otherwise  per- 
verted.    Error  indeed  is  easy,  but  to  avoid  it,  requires  in  this,  as  in 
most  instances,  not  so  much  great  acuteness,  as  great  care  and  great 
patience. 

The  pain  with  which  pleurisy  sets  in  is  sometimes  referred  not  to  the 
chest,  but  to  the  abdomen;  and  its  commencement  maybe  attended 
with  vomiting  and  purging.  Pressure  on  the  abdomen,  too,  often 
causes  a  considerable  increase  of  suffering ;  and  you  may  thus  be  led 
to  regard  the  case  not  as  pleurisy,  but  as  intestinal  disorder,  with  fever. 
In  any  such  doubtful  case  it  is  well  to  bear  in  mind  that  children,  long 
after  they  can  talk,  describe  the  nature  and  seat  of  their  sufferings 
very  inaccurately  ;  and  if,  as  often  happens  in  these  cases,  they  refer 
the  pain  to  the  right  hypochondrium,  you  should  not  forget  that  pain 
in  that  situation  is  at  all  ages  much  oftener  connected  with  inflamma- 
mation  of  the  pleura  than  of  the  peritoneum;  and,  lastly,  that  tho 


DIAGNOSIS   OF  PLEURISY.  211 

increase  of  discomfort  produced  by  pressure  on  the  abdomen,  may  be 
due  to  the  additional  impediment  thereby  offered  to  the  already  labour- 
ing respiration. 

In  most  cases  of  pleurisy  in  childhood,  careful  auscultation  will 
preserve  us  from  error.  Still,  the  information  that  it  yields  is  more 
limited  in  the  child  than  in  adult  age.  The  evidence  afforded  by  the 
various  modifications  of  the  voice  sound,  are  much  less  marked,  owing 
to  the  feebleness  of  the  voice  in  early  life,  while  we  cannot  induce  the 
child  to  speak  several  sentences,  or  utter  several  words  in  the  same 
pitch  of  voice,  in  order  that  we  may  try  how  far  the  sound  is  altered. 
For  the  same  reason,  too,  we  cannot  test  the  difference  between  the  two 
lungs  by  the  vibration  of  the  voice  perceived  on  applying  the  hands  to 
either  side  of  the  chest — a  means  by  which,  in  the  adult,  we  are  often 
assisted  in  determining  between  a  solidification  of  the  lung  from  pneu- 
monia, and  the  dulness  consequent  on  pleurisy  with  effusion.  Another 
circumstance  which,  in  the  child,  increases  the  difficulty  of  distinguish- 
ing between  pleurisy  and  pneumonia,  is,  that,  in  the  latter,  children 
sometimes  inspire  so  slightly  as  not  to  produce  any  crepitation  ;  so  that 
in  both  cases  we  may  have  impaired  resonance  on  percussion,  with 
scanty  admission  of  air,  and  a  bronchial  character  in  the  respiration, 
but  without  any  other  morbid  sound.  In  the  child,  too,  we  lose  the 
very  valuable  information  which  the  presence  of  the  expectoration  in 
the  pneumonia  of  grown  persons  affords,  when  contrasted  with  the 
absence  of  all  expectoration  as  an  attendant  on  the  dry  cough  of 
pleurisy.  With  the  advance  of  the  disease  doubt  as  to  its  nature  is 
removed  ;  it  is  at  its  commencement  only  that  mistake  is  possible. 
But  even  then,  and  in  spite  of  all  the  circumstances  which  have  been 
enumerated  as  tending  to  mislead,  you  will  seldom  be  wrong  if  you 
regard  as  an  instance  of  pleurisy  any  case  in  which  s}^mptoms  like 
those  of  pneumonia  have  set  in  suddenly  and  severely,  auscultation 
fails  to  detect  the  crepitus  of  pneumonia,  and  discovers  only  feebleness 
of  the  respiratory  murmur  on  one  side,  with  or  without  a  more  or  less 
marked  bronchial  character  in  the  breathing. 

But  we  may  pass  now  to  the  consideration  of  the  treatment  of  acute 
pleurisy  in  childhood;  a  subject  which  need  not  detain  us  long,  since 
the  age  of  the  patient  in  no  respect  alters  the  principles  that  must 
guide  our  conduct.  If  seen  sufficiently  early,  and  treated  with  due 
activity,  cases  of  acute  pleurisy  in  infancy  and  childhood  nearly  always 
have  a  favourable  termination,  and  in  almost  every  instance  that  has 
come  under  my  observation  in  which  the  issue  of  the  disease  was  unfor- 
tunate, either  all  treatment  had  been  neglected  until  the  children  were 
past  hope,  or  the  nature  of  the  complaint  had  been  mistaken,  or  the 
treatment  followed  had  not  been  sufficiently  active.  This  last  error, 
it  is  of  great  moment  to  avoid,  for  acute  inflammation  of  the  pleura  in 
childhood  runs  its  course  with  greater  rapidity  to  a  fatal  issue  than  in 
the  adult.  Of  seven  fatal  cases  of  acute  pleurisy  in  childhood,  of 
which  I  have  preserved  a  record,  three  ended  in  death  on  the  6th  day, 
one  on  the  9th,  one  within  a  fortnight;  while  one  of  the  remaining 
two  terminated  in  thirty  days,  and  the  life  of  the  child  in  the  seventh 


212  ITS  TREATMENT. 

case  was  prolonged  for  several  months,  death  eventually  taking  place 
from  the  developement  of  phthisical  disease  in  the  lungs. 

In  almost  every  case,  provided  the  symptoms  be  at  all  urgent,  and 
the  child's  previous  health  have  been  good,  general  depletion  should 
be  resorted  to,  and  you  need  not  be  afraid  of  carrying  this  first  bleed- 
ing to  syncope,  since  children  generally  faint  after  the  abstraction  of 
a  comparatively  small  quantity  of  blood  from  the  arm.  It  will  be 
almost  always  necessary  to  follow  this  up  by  local  bleeding,  but  it  is 
desirable  to  wait  for  three  or  four  hours  in  order  that  you  may  be 
enabled  to  estimate  the  effect  produced  by  the  previous  venesection. 
A  second  bleeding  from  the  arm  is  seldom  needed,  and  may  almost 
always  be  avoided  if  local  depletion  be  not  too  timorously  practised. 
In  the  acute  stage  of  pleurisy,  it  is  better  to  draw  the  blood  by  leeches 
than  by  cupping,  since  the  side  is  often  so  tender  that  the  pressure  of 
cupping  glasses  would  be  unbearable.  After  depletion,  our  chief 
reliance  is  to  be  placed  on  calomel,  which  should  be  freely  given  in 
combination  with  opium  or  Dover's  powder.  Antimony,  which  often 
renders  us  such  good  service  in  pneumonia,  is  here  of  little  use  ;  and 
though  it  may  somewhat  diminish  the  frequency  of  the  breathing,  it 
exerts  little  or  no  influence  upon  the  local  mischief.  A  pleurisy  treated 
thus  actively,  is  sometimes  overcome  in  the  course  of  24  or  48  hours, 
so  that  nothing  remains  of  symptoms  which  had  appeared  so  formida- 
ble. Often,  however,  after  the  acute  symptoms  have  subsided,  the 
affected  side  remains  dull,  and  the  respiration  scanty,  for  several  weeks 
together  ;  and  now  is  the  time  when  the  use  of  blisters,  associated  with 
the  exhibition  of  small  doses  of  calomel,  will  be  of  most  essential  ser- 
vice, and  will  generally  effect  the  complete  absorption  of  the  fluid,  and 
the  restoration  of  the  patient  to  perfect  health. 

This,  however,  is  not  always  the  case ;  but  sometimes,  in  spite  of 
remedies  perseveringly  employed,  one  side  of  the  chest  continues  full 
of  fluid  ;  and  the  question  then  comes  before  us,  whether  it  will  not  be 
expedient  to  let  out  that  fluid  by  mechanical  means.  Many  most 
important  considerations,  are,  as  you  know,  involved  in  the  question  of 
performing  paracentesis  of  the  chest ;  but  the  indications  for  its  per- 
formance are  the  same  in  the  child  as  in  the  adult :  while  my  own 
experience  would  lead  me  to  conclude  that  cases  in  which  the  operation 
is  necessary,  are  of  very  rare  occurrence  in  early  life. 

Pleurisy  does  not  always  present  itself  as  an  idiopathic  affection.  It 
supervenes,  as  we  have  already  noticed,  in  the  course  of  pneumonia, 
increasing  the  suffering  of  the  patient,  and,  if  severe,  adding  much  to 
his  danger.  It  comes  on  sometimes  during  acute  rheumatism,  either 
with  or  without  pericarditis,  and  on  two  occasions  I  have  observed 
pleurisy,  with  effusion  into  one  side  of  the  chest,  succeed  to  an  attack 
of  peritonitis.  But  besides  these  cases  in  which  the  affection  of  the 
pleura  retains  an  acute  character,  the  disease  is  likewise  met  with  in  a 
chronic  form,  and  manifesting  its  existence  by  comparatively  few 
symptoms.  Attacks  of  chronic  pleurisy  are  sometimes  idiopathic,  and 
it  is  not  always  possible  to  trace  them  back  to  their  commencement  in 
an  acute  seizure.     The  cough  and  dyspnoea  in  such  cases  are  trouble- 


CHRONIC  PLEURISY.  211 


some  rather  than  distressing,  and  nothing  but  examination  of  the  chest 
would  lead  to  a  suspicion  of  the  serious  nature  of  the  affection.  Cases 
of  this  description  usually  do  well  under  the  employment  of  local 
counter-irritation  and  the  administration  of  mercury  and  diuretics, 
though  the  absorption  of  the  fluid  is  in  general  effected  very  gradually. 
Chronic  pleurisy,  however,  is  a  very  rare  occurrence  as  a  purely  idio- 
pathic affection  in  early  life  ;  but  it  is  one  of  the  most  important,  and 
far  from  being  one  of  the  least  common  complications  of  the  dropsy 
which  often  succeeds  to  scarlatina.  Under  these  circumstances,  too, 
it  often  needs  much  attention  to  detect  it,  since  it  may  for  a  long 
time  give  rise  to  but  few  symptoms  that  might  betray  its  existence. 
Some  cough  and  some  dyspnoea  almost  invariably  attend  the  anasarca 
that  succeeds  scarlatina,  and  often  there  is  no  complaint  of  pain,  nor 
increase  of  the  cough,  nor  exaggeration  of  the  dyspnoea,  to  betoken  the 
onset  of  this  new  and  formidable  disease.  At  length,  perhaps,  the 
anasarca  disappears,  and  now,  when  we  notice  the  emaciated  condition 
of  the  child,  we  observe  for  the  first  time,  that  one  half  of  the  chest  is 
much  larger  than  the  other,  that  it  remains  immoveable  during  respi- 
ration, and  we  discover  that  it  is  full  of  fluid.  Or,  our  attention  may 
be  suddenly  called  to  the  mischief  that  has  been  going  on,  by  the 
child  becoming  unable  to  breathe,  except  in  one  posture,  and  even  then 
with  extreme  difficulty :  the  fluid  has  been  poured  out  so  abundantly 
as  at  length  almost  to  prevent  respiration,  and  when  we  find  out  the 
evil,  it  is  almost  too  late  to  effect  its  cure. 

It  is  by  the  adoption  of  a  vigorous  antiphlogistic  treatment  in  the 
dropsy  that  follows  scarlatina  that  you  will  be  most  likely  to  prevent 
the  supervention  of  this  serious  malady  :  it  is  only  by  the  most  atten- 
tive daily  auscultation  that  you  will  in  many  cases  get  notice  of  its 
approach. 


LECTUKE  XIX. 

Croup. — Reasons  for  not  studying  it  earlier  in  the  course — discrepancy  of  opinion  with 
reference  to  it,  owing  to  modifications  of  its  character  by  external  circumstances. 

Causes  of  the  disease — its  frequency  in  childhood,  in  the  male  subject,  in  northern 
climates,  in  rural  districts — its  occasional  epidemic  prevalence. 

Post-mortem  appearances — variations  in  the  extent  of  false  membrane  in  the  air- 
passages — changes  associated  with  it — affection  of  the  fauces  and  soft  palate. 

Symptoms — occasional  sudden  onset — catarrhal  stage,  general  course  of  a  fatal  case — 
occasional  delusive  appearances  of  amendment. — Evidences  of  auscultation — changes 
in  tracheal  sound. 

Duration.     Prognosis. 

Treatment — importance  of  abstraction  of  blood — directions  for  its  performance,  and  for 
the  administration  of  tartar-emetic — when  and  how  mercurials  are  to  be  employed. 

In  strict  propriety  the  very  important  disease  which  we  are  about  to 
investigate  to-day  ought  to  have  engaged  our  attention  immediately 
after  we  had  completed  our  study  of  infantile  bronchitis.  Two  reasons, 
however,  independent  of  mere  convenience,  have  led  me  to  postpone 
till   now  the   consideration   of  the   subject  of  croup.     One  of  these 


214  croup. 

reasons  is  that  its  gravity  is  often  greatly  increased  by  the  association 
with  it  of  inflammation  of  the  lungs, — a  complication  the  importance  of 
which  it  was  essential  that  you  should  thoroughly  understand  ;  the 
other  is,  that  croup,  though  an  inflammatory  disease,  is  not  without  a 
very  evident  spasmodic  element  in  every  case  :  so  that  it  may  very 
appropriately  form  a  sort  of  transition  between  the  inflammatory  and 
the  spasmodic  diseases  of  the  respiratory  organs. 

It  can  scarcely  be  necessary  to  tell  any  of  you  that  croup  is  the 
English  name  for  the  disease  designated  by  scientific  writers  eynanche 
trachealis,  or  eynanche  laryngea.  It  consists  in  inflammation  generally 
of  a  highly  acute  character,  of  the  larynx  or  trachea,  or  of  both,  which 
terminates  in  the  majority  of  cases  in  the  exudation  of  false  membrane 
more  or  less  abundantly  upon  the  affected  surface. 

The  formidable  nature  of  the  symptoms  by  which  it  is  attended,  and 
the  rapidity  with  which  it  tends  to  a  fatal  issue,  have  led  many  of  the 
ablest  physicians  to  devote  much  time  and  attention  to  the  study  of 
croup.  It  might  therefore  be  anticipated  that  our  knowledge  of  a 
disease  which  betrays  itself  by  very  manifest  and  highly  characteristic 
symptoms,  and  which  gives  rise,  when  fatal,  to  changes  easily 
appreciable  after  death,  should  by  this  time,  be  very  definite  and 
settled.  With  reference  to  many  of  the  more  important  points  in  the 
history  of  the  malady,  writers  are  now,  indeed,  pretty  well  agreed  ; 
but  croup,  like  many  other  diseases  that  depend  to  a  great  degree  on 
atmospheric  and  telluric  causes,  is  modified  in  many  of  its  symptoms 
by  peculiarities  of  air,  water,  and  situation.  The  affection  assumes 
one  character  among  the  poor  of  a  crowded  city  and  another  among 
the  children  of  the  labourer  in  some  rural  district.1 

1  I  have  preserved  a  record  of  23  cases  of  croup  that  came  under  ray  notice  at  the 
lloyal  Infirmary  for  Children  between  May  1839  and  April  1849.  Of  these  23  cases,  11 
were  idiopathic,  12  secondary:  five  of  the  former  and  two  of  the  latter  recovered.  In 
two  of  the  idiopathic  cases  that  recovered,  a  scanty  formation  of  false  membrane  was 
observed  upon  the  velum  and  tonsils,  but  no  such  appearance  existed  in  the  other 
idiopathic  cases.  Three  of  the  six  fatal  idiopathic  cases  were  examined  after  death: 
in  two  the  false  membrane  was  confined  to  the  laryux  ;  and  there  was  but  little  injec- 
tion of  the  trachea  or  bronchi :  in  the  third  case  there  was  great  redness  both  of  the 
trachea  and  bronchi,  and  a  large  quantity  of  purulent  secretion  in  both,  and  ulceration 
of  the  mucous  membrane  of  the  larynx,  but  no  false  membrane.  Of  the  12  secondary 
cases  one  supervened  in  the  course  of  pneumonia ;  in  the  other  eleven,  croup  appeared 
as  the  sequela  or  concomitant  of  measles,  and  ten  of  the  twelve  terminated  fatally. 
In  the  cases  which  recovered,  and  in  three  of  those  which  terminated  fatally,  there  was 
no  false  membrane  on  the  velum  or  fauces,  but  in  the  other  seven,  false  membrane  was 
present  in  those  situations  as  well  as  in  the  larynx,  and  twice  this  false  membrane 
extended  into  the  oesophagus.  Six  of  the  fatal  cases  were  examined  after  death ;  in  one 
there  was  no  false  membrane  anywhere,  but  intense  redness  of  the  larynx,  trachea,  and 
bronchi,  with  an  uneven  granular  appearance  of  the  larynx,  and  ulceration  about  the 
epiglottis.  In  the  other  five  cases  the  larynx  contained  more  or  less  false  membrane, 
and  its  surface  was  ulcerated ;  and  in  four  of  the  cases  the  palate  and  tonsils  were 
inflamed  and  coated  with  false  membrane.  In  all  these  five  cases  pneumonia  existed  in 
both  lungs,  and  four  times  it  was  found  to  have  reached  in  some  parts  the  stage  of 
purulent  infiltration. 

These  results,  which  differ  in  so  many  respects  from  the  conclusions  of  many  most 
excellent  observers  in  this  country,  approach  much  more  nearly  to  those  obtained  in 
the  Hopital  des  Enfans  Malades  at  Paris.  The  district  in  which  my  observations  were 
made  is  low,  with  defective  sewerage,  open  drains  running  close  to  many  of  the  houses ; 
and  most  of  the  patients  were  the  children  of  poor  parents,  who  occupied  only  one 
room,  and  who  consequently  were  placed  in  most  unfavourable  hygienic  conditions. 


CAUSES   OP   CROUP.  215 

If,  therefore,  you  find  that  my  account  of  the  disease  varies  in  any 
respect  from  the  description  given  by  some  other  writers,  or  from  the 
results  of  your  own  observation  hereafter,  do  not  too  hastily  assume 
either  that  your  teacher  has  been  mistaken,  or  that  your  own  obser- 
vation has  been  incorrect.  The  difference  may  be  nothing  more  than 
a  fresh  exemplification  of  the  old  story  of  the  shield,  silver  on  the  one 
side,  and  golden  on  the  other,  about%  which  the  knights  in  the  fable 
quarrelled. 

Croup,  in  all  the  forms  which  it  assumes  in  this  country,  is  essentially 
a  disease  of  early  life  ;  for  it  appears  from  the  Fifth  lleport  of  the 
Registrar-General,  that,  while  1022  out  of  98,391  deaths  in  the 
metropolis,  and  twenty-four  town  districts,  took  place  from  croup,  1013, 
or  99-9  per  cent,  of  those  deaths  occurred  before  the  age  of  fifteen  ; 
and  879,  or  87'9  per  cent,  before  the  age  of  five  years.  Of  twenty-six 
cases  of  croup  of  which  I  have  preserved  a  record,  twenty-five  occurred 
in  children  under  five  years  of  age,  and  twelve  in  children  under  two. 
It  has  been  attempted  to  explain  this  great  frequency  of  croup  in  early 
life  by  the  imperfect  development  of  the  organ  of  the  voice  before 
puberty.  This,  however,  can  scarcely  be  admitted  as  a  valid  expla- 
nation, since  it  does  not  at  all  account  for  the  extreme  rarity  of  the 
disease  after  five  years  of  age.  The  preponderance  of  male  over 
female  children,  among  those  who  are  attacked  by  croup,  is  another 
fact  which,  though  confirmed  by  the  experience  of  all  observers,  has 
never  received  any  adequate  explanation.1 

Croup  appears  to  be  influenced  by  peculiarities  of  climate  and 
locality  much  more  than  most  diseases  even  of  the  respiratory  organs. 
Though  not  entirely  confined  to  northern  climates,  it  prevails  but 
seldom  in  the  southern  parts  of  Europe,  and  is  even  less  frequent  in  the 
southern  than  in  the  northern  counties  of  England.  In  Kent,  Surrey, 
and  Sussex,  the  deaths  from  croup  are  to  the  deaths  from  all  causes  in 
the  proportion  of  9  per  cent. ;  while  in  the  four  northern  counties, 
Durham,  Northumberland,  Cumberland,  and  Westmoreland,  which  con- 
tain an  equal  population,  the  deaths  from  this  cause  are  in  the 
proportion  of  1*6  per  cent.  It  is  endemic  in  particular  localities;  and 
residence  near  the  sea,  proximity  to  the  mouths  of  large  rivers,  a  moist 
soil  and  a  damp  atmosphere,  have  been  enumerated  as  greatly  predis- 
posing to  the  disease.  The  influence  of  these  local  peculiarities  has 
probably,  in  some  instances,  been  overrated ;  but  still  it  cannot  be 
denied,  for  a  most  striking  illustration  of  it  is  afforded  by  the  com- 
parative rarity  of  croup  in  towns,  and  its  frequency  in  rural  districts. 
In  the  county  of  Surrey,  exclusive  of  the  metropolitan  districts,  the 
mortality,  from  all  causes,  under  five  years  of  age,  is  little  more  than  a 
third  of  the  mortality,  in  Liverpool,  and  a  little  more  than  half  the 
mortality  in  London.     But  the  total  mortality,  under  five  years  of  age, 

1  From  the  Fifth  Report  of  the  Registrar-General,  it  appears  that,  while  the  deaths 
of  males  under  15  from  all  causes,  are  to  the  deaths  of  females  from  all  causes  as  11 
to  10,  the  deaths  from  croup  are  as  15  to  10.  Of  249  cases  that  came  under  Golis' 
observation  at  Vienna,  144  occurred  in  males,  105  in  females;  and  at  Geneva,  under 
J  urine's  observation,  51  males  and  37  females  died  of  croup,  between  the  years  1791 
and  1808. 


216  MORBID   APPEARANCES. 

from  croup  in  the  county  of  Surrey  is  to  that  in  Liverpool  nearly  as 
o  to  2,  and  to  that  in  London  as  2  to  1  ;  so  that  out  of  100  children 
dying  under  five  years  of  age  from  all  causes,  more  than  four  times 
as  many  will  have  died  from  croup  in  Surrey  as  in  Liverpool,  and 
exactly  four  times  as  many  as  in  London. 

Like  other  diseases  that  are  much  influenced  by  local  and  atmo- 
spheric peculiarities,  croup  has  i^  periods  of  epidemic  prevalence.  The 
most  remarkable  epidemic  of  croup  occurred  in  the  years  1805,  6,  and 
T,  when  it  extended  over  the  greater  part  of  central  Europe.  The 
death  of  Napoleon's  nephew,  the  Crown  Prince  of  Holland,  at  this 
time,  gave  occasion  to  the  offer  of  a  prize  by  the  Emperor  for  the  best 
essay  on  this  disease;  to  which  we  are  indebted  for  many  most  valu- 
able works  on  croup.  Since  then  a  sudden  increase  in  its  prevalence 
has  been  noticed  from  time  to  time  in  certain  towns  or  districts, 
sufficient  to  show  that  the  disease  depends  much  on  variations  in  the 
atmosphere,  though  it  has  never  again  become  so  widely  diffused  over 
large  tracts  of  country  as  in  the  year  1807.  In  Paris,  during  the  year 
1840,  twice  as  many  deaths  occurred  from  croup  as  had  taken  place  in 
1838;  and  there  was  a  similar  epidemic  prevalence  of  the  disease  in 
London  during  the  years  1841  and  1842. 

Variations  in  the  condition  of  the  atmosphere,  and  peculiarities  of 
situation,  not  only  influence  the  frequency  of  the  occurrence  of  croup, 
but  they  likewise  greatly  modify  its  character,  and  determine  to  a 
considerable  extent  the  nature  of  the  lesions  which  it  produces.  The 
chief  morbid  appearances,  however,  are  always  discovered  in  the 
larynx,  trachea,  and  air  tubes.  They  consist  of  redness  of  the  mucous 
membrane,  which  is  often  thickened,  sometimes  abraded  or  ulcerated, 
and  very  generally  covered  with  a  more  or  less  abundant  exudation  of 
false  membrane.  This  exudation,  however,  though  so  generally  met 
with  as  to  have  suggested  to  medical  writers  the  terms  angina  poly- 
posa,  angina  membranacea,  as  appropriate  designations  of  croup,  is 
neither  invariable  in  its  occurrence,  nor  of  a  uniform  extent  in  all 
cases.  It  is  found  in  the  larynx  oftener  than  in  the  trachea,  and  in 
both  more  frequently  than  in  the  bronchi.  There  are  nevertheless, 
many  instances  on  record  in  which  the  secretion  of  false  membrane 
was  so  extensive  that  it  not  only  lined  the  larynx  and  trachea,  but 
reached  into  the  minuter  air-tubes,  forming  a  complete  cast  of  many  of 
their  ramifications.  There  appears  to  be  some  connection  between  the 
circumstances  under  which  children  become  attacked  by  croup,  and  the 
extent  of  false  membrane  in  the  air-passages,  which  a  post-mortem 
examination  reveals.  In  rural  districts,  where  the  disease  wears 
throughout  a  sthenic  character,  false  membrane  is  deposited  in  greater 
abundance,  and  over  a  greater  extent  of  surface,  «than  is  usually 
observed  in  the  case  of  the  poor  in  this  metropolis :  while,  on  the  other 
hand,  we  find  in  London  a  condition  of  unhealthy  ulceration  about  the 
larynx;  ulceration,  and  the  deposit  of  false  membrane  about  the  tonsils 
and  palate,  in  many  instances:  appearances  which  are  seldom  met  with 
in  children  placed  under  circumstances  more  favourable  to  health. 

In  cases  of  croup  that  have  come  under  my  own  observation,  the  for- 
mation of  false  membrane  in  the  larynx  has  seemed  almost  invariably. 


MORBID   APPEARANCES   IN   CROUP.  217 

to  precede  its  deposit  in  the  trachea ;  and  not  infrequently  it  has  been 
found  constituting  a  tough,  continuous,  membrane,  in  the  former  situa- 
tion, but  growing  less  tenacious  in  the  upper  part  of  the  trachea,  and 
passing  gradually  into  a  thick,  puriform  mucus,  interspersed  with 
shreds  of  lymph.  I  have  usually  observed  the  false  membrane  lining 
the  whole  of  the  larynx,  and  reaching  down  to  the  lower  edge  of  the 
thyroid  cartilage,  while  the  trachea  contained  nothing  else  than  a 
puriform  matter,  or  glairy  mucus,  sometimes  of  a  reddish  colour.  In 
some  instances  the  false  membrane  has  been  confined  to  the  upper  part 
of  the  larynx,  lining  the  lower  surface  of  the  epiglottis,  blocking  up 
the  opening  of  the  sacculus  laryngis,  and  covering  the  chordae  vocales, 
but  not  extending  any  further.  When  first  secreted,  the  false  mem- 
brane is  firmly  adherent  to  the  mucous  lining  of  the  air-passages,  but 
after  a  time  a  secretion  of  a  puriform  character  is  generally  poured 
out,  which  detaches  the  membrane  from  its  connections ;  and  it  is  after 
this  occurrence  has  taken  place  that  tubular  pieces  of  false  membrane 
have  sometimes  been  expectorated.  This  detachment  of  the  false 
membrane  from  the  subjacent  surface  takes  place  more  frequently  and 
more  completely  from  the  interior  of  the  trachea  than  from  that  of  the 
larynx.  On  removing  the  false  membrane  from  the  trachea,  the  lining 
of  the  tube  is  seldom  found  to  present  any  change  other  than  an 
increase  of  its  vascularity,  which  though  sometimes  very  considerable, 
does  not  bear  any  certain  relation  to  the  amount  of  false  membrane 
present.  The  greater  difficulty  in  removing  the  false  membrane  from 
the  larynx  depends  upon  the  more  extensive  alterations  which  the 
lining  of  that  part  of  the  air-tube  is  usually  found  to  have  undergone. 
It  is  generally  red  and  swollen,  especially  about  the  edges  of  the  rima 
glottidis  and  the  arytenoid  cartilages,  and  the  openings  of  the  sacculus 
laryngis.  Small  aphthous  ulcerations  are  also  frequent  in  the  two 
former  situations ;  and  occasionally,  the  ulcerations  being  more  exten- 
sive, the  whole  of  the  larynx,  on  detaching  the  false  membrane  that 
lined  it,  presents  a  worm-eaten  appearance. 

It  seldom  happens  that  the  bronchi  are  perfectly  free  from  disease ; 
but  even  though  the  trachea  contain  no  false  membrane,  and  present 
but  few  signs  of  inflammation,  they  are  almost  always  much  congested, 
and  contain  a  muco-purulent  or  purulent  secretion ;  though  false  mem- 
brane is  seldom  found  in  them,  except  when  it  is  continuous  with  a 
similar  adventitious  structure  in  the  trachea. 

Pneumonia,  in  all  its  stages,  is  far  from  being  unusual,  and  is  a  com- 
plication especially  to  be  feared  in  those  cases  where  croup  occurs  as  a 
secondary  affection  in  the  course  of  measles. 

The  cavity  of  the  mouth,  and  the  fauces,  do  not  present  any  invari- 
able alteration  in  cases  of  croup.  Congestion  about  the  fauces  and 
soft  palate  is  of  frequent  occurrence,  sometimes  coupled  with  a  scanty 
deposit  of  false  membrane  in  those  situations,  or  the  tonsils  are  found 
in  a  state  of  sloughing  ulceration.  In  that  form  of  croup  which  suc- 
ceeds to  measles,  there  is  moreover  in  many  instances  a  condition  of 
unhealthy  inflammation,  and  aphthous  ulceration  of  the  mouth  and 
gums :  a  slight  speck  of  ash-coloured  false  membrane  covering  each 


218  SYMPTOMS   OP   THE   FIRST    STAGE. 

little  ulcer.  In  many  of  these  cases  I  apprehend  that  the  laryngeal 
affection  does  not  come  on  in  consequence  of  extension  to  the  air- 
passages  of  disease  beginning  in  the  mouth,  but  that  the  disease  is  the 
same  in  both  situations;  though  the  accident  of  the  locality  renders 
that  a  serious  disorder,  when  seated  in  the  larynx,  which  is  but  a 
trivial  ailment  when  affecting  the  mouth.  Cases  of  this  last  kind  have 
been  called  cases  of  ulcerative  laryngitis :  they  have  always  come 
under  my  notice  associated  with  the  effusion  of  false  membrane,  and 
between  them  and  croup  I  can  discover  no  essential  difference. 

Whatever  be  the  circumstances  under  which  croup  comes  on,  the 
symptoms  resulting  from  disease  obstructing  the  channel  of  the  larynx 
and  trachea  by  false  membrane,  or  inducing  a  spasmodic  closure  of 
their  aperture,  must  always  be  to  a  great  extent  the  same.  The  mode 
of  onset  of  the  disease,  however,  is  very  variable.  Sometimes,  espe- 
cially in  those  forms  of  croup  that  prevail  among  healthy  children 
living  in  the  country,  the  disease  is  announced  by  few,  if  any,  pre- 
monitory symptoms  ;  but  the  affection  of  the  larynx  is  apparent  from 
the  very  outset,  and  attains  in  the  course  of  a  few  hours  to  a  high 
degree  of  intensity.  Some  years  since  I  saw  a  little  boy,  about  seven 
years  old,  living  at  some  distance  from  London.  He  had  overheated 
himself  at  play  during  the  afternoon  of  a  hot  day  in  August,  but  went 
to  bed  apparently  well  at  eight  o'clock,  and  soon  fell  asleep.  At  ten, 
he  began  to  breathe  with  the  peculiar  noise  characteristic  of  croup,  and 
presented  all  the  symptoms  of  the  disease  before  midnight. 

In  his  treatise  on  croup,  Professor  Golis,  of  Vienna,1  relates  the  case 
of  a  little  boy  four  years  old,  previously  in  perfect  health,  who  having 
gone  out  of  an  overheated  room  into  the  open  air,  during  an  extremely 
cold  winter's  day,  was  seized  while  walking  with  all  the  symptoms  of 
most  violent  croup,  which  proved  fatal  in  fourteen  hours. 

This  sudden  onset  and  rapid  course  of  the  disease,  however,  are  of 
rare  occurrence,  and  croup  generally  comes  on  gradually,  attended  in 
its  first  stage  with  but  few  symptoms  that  could  distinguish  it  from 
ordinary  catarrh.  Slight  fever,  drowsiness,  suffusion  of  the  eyes,  and 
defluxion  from  the  nares,  attend  it.  The  respiration  is  not  perceptibly 
disturbed,  and  the  cough,  though  frequent,  presents  no  peculiar  cha- 
racter. There  is,  besides,  occasional  complaint  of  slight  sore  throat,,  or 
of  uneasy  sensation  about  the  larynx,  but  so  slight  as  scarcely  to 
attract  attention,  and  not  sufficient  to  cause  any  alarm. 

The  duration  of  this  stage  is  very  variable :  nor  is  there  any  regu- 
larity in  the  mode  of  its  transition  into  the  second  stage.  In  the 
majority  of  cases,  indeed,  the  transition  takes  place  gradually ;  but 
thirty-six  hours  seldom  pass  without  the  supervention  of  some  symptom 
which,  to  the  well-schooled  observer,  would  betray  the  nature  of  the 
coming  danger.  Most  symptoms  may  continue  unchanged,  perhaps 
scarcely  aggravated,  but  a  slight  modification  takes  place  in  the  cha- 
racter of  the  cough,  which  now  becomes  attended  with  a  peculiar  ringing 
sound,  difficult  to  describe,  but  when  once  heard  not  easily  forgotten. 

1  De  rite  cognescenda  et  sananda  Angina  Membranacea,  8vo.  Yiennae.  Observ.  iv. 
p.  141. 


SYMPTOMS   OP   THE   SECOND   STAGE   OF   CROUP.  219 


This  peculiarity  in  the  cough  very  often  precedes  any  change  in  the 
respiration,  and  may  sometimes  be  so  slight  as  scarcely  to  attract  the 
parents'  notice  at  the  time,  and  to  be  remembered  only  when  the  lull 
development  of  the  disease  leads  to  inquiries  as  to  how  the  attack  came 
on.  Soon  after  this  modification  of  the  cough  has  become  perceptible, 
or  even  simultaneously  with  it,  the  respiration  undergoes  a  change  no 
less  remarkable.  The  act  of  inspiration  becomes  prolonged,  and 
attended  with  a  stridor  as  difficult  to  describe,  but  as  characteristic  of 
the  disease,  as  the  tone  of  the  cough.  It  often  happens  that  these  two 
pathognomonic  symptoms  first  come  on,  or  at  least  first  excite  atten- 
tion, in  the  night,  and  that  a  child  who  at  bed-time  was  supposed  to  ail 
nothing,  or  at  most  to  have  a  slight  cold,  awakes  suddenly  with  ringing 
cough  and  stridulous  breathing,  frequently  in  a  state  of  alarm  and  with 
marked  dyspnoea.  Through  the  whole  course  of  the  disease,  indeed,  an 
obvious  tendency  exists  to  nocturnal  exacerbations,  and  to  remissions 
as  the  morning  approaches.  In  whatever  manner  these  symptoms  may 
have  come  on,  they  will  not  continue  for  many  hours  without  being 
attended  by  increase  of  fever,  by  acceleration,  and  soon  by  difficulty 
of  respiration.  The  skin  becomes  hot  and  dry,  the  face  flushed,  the 
breathing  hurried,  the  cough  frequent,  the  pulse  full  and  quick,  the 
child  dull,  fretful,  and  passionate.  For  a  few  minutes,  indeed,  it  may 
appear  cheerful,  may  turn  to  its  playthings,  and  breathe  more  natu- 
rally, though  the  peculiar  respiratory  sound  never  ceases  altogether. 
Soon,  however,  the  dyspnoea  returns  with  increased  intensity ;  the 
whole  chest  heaves  with  the  inspiratory  effort,  which  is  more  prolonged 
and  attended  with  greater  stridor.  During  it,  perspiration  breaks  out 
at  every  pore,  and  the  veins  of  the  neck  and  face  become  greatly  dis- 
tended. Short  and  forcible  expiration  follows,  and  after  this  state  of 
dyspnoea  has  lasted  for  some  minutes,  an  interval  of  comparative  ease 
succeeds.  The  child  now  often  falls  asleep  exhausted:  but  during  sleep, 
the  sound  attending  respiration  is  heard  in  an  exaggerated  degree. 
Though  the  drowsiness  is  great,  sleep  is  uneasy,  and  frequently  inter- 
rupted by  violent  startings,  in  spite  of  which  the  child  may  still  sleep 
on.  After  some  minutes  he  awakes  in  a  state  of  terror,  to  pass  through, 
another  paroxysm  similar  to  the  preceding  one,  though  more  severe. 
The  cough  does  not  increase  in  severity  in  proportion  as  the  disease 
advances ;  it  is  unattended  by  expectoration,  or  at  most  a  little  mucus 
is  spit  up,  but  without  any  relief.  Although  the  paroxysms  of  dyspnoea 
are  not  dependent  on  the  cough,  they  are  sometimes  provoked  by  it, 
and  the  two  or  three  inspirations  next  following  an  effort  of  coughing 
are  often  attended  with  increased  stridor.  From  the  first  appearance 
of  the  more  marked  symptoms,  the  voice  is  hoarse,  cracked,  and  whis- 
pering, or  in  young  children  is  either  totally  suppressed,  or,  if  their 
voice  be  not  actually  extinct,  at  least  their  disinclination  to  speak  is  so 
great,  that  they  will  reply  to  questions  only  by  signs,  and  cannot  be 
induced  by  any  persuasion  to  utter  a  wTord. 

There  is  almost  always  much  eagerness  for  drink,  and  deglutition  is 
generally  well  performed.  The  fauces  are  often  red,  though  their  red- 
ness bears  no  direct  proportion  to  the  intensity  of  the  croupal  symptoms ; 


220  OF  ITS   THIRD   STAGE. 

and  there  is  frequently  considerable  tenderness  of  the  larynx.  The 
tongue  is  red  at  the  tip  and  edges,  but  coated  in  the  centre  and  at  the 
back  with  thick  white  fur ;  the  bowels  are  rather  constipated,  and  the 
appetite  for  food  is  entirely  lost. 

As  the  disease  advances,  the  paroxysms  become  less  marked,  or  rather, 
the  intermissions  grow  less  distinct,  and  the  child  is  constantly  engaged 
with  the  effort  to  respire.  The  cough  now  sometimes  ceases  altogether, 
and  the  breathing  frequently  becomes  sibilant  rather  than  stridulous. 
The  child  throws  its  head  back  as  far  as  possible,  in  order  to  increase  the 
capacity  of  the  trachea,  the  chest  is  heaved  violently  at  each  effort  to 
inspire,  and  the  larynx  is  depressed  forcibly  towards  the  sternum,  while 
the  abdominal  muscles  co-operate  energetically  in  expiration.  The  face 
is  heavy  and  anxious,  the  eyes  are  dull,  the  lips  livid,  the  skin  dry,  and 
the  extremities  cold  ;  or  clammy  sweats  bedew  the  surface.  The  respi- 
ration is  hurried,  unequal  and  irregular,  and  the  pulse  is  very  frequent 
and  very  feeble.  Though  no  remissions  now  occur,  there  are  frequent 
exacerbations,  in  which  the  child  throws  itself  about,  and  puts  its  hand 
to  its  throat,  as  though  to  tear  away  some  obstacle  to  the  admission  of 
air,  while  helpless,  hopeless  agony,  is  depicted  on  its  countenance.  In 
the  midst  of  these  sufferings  the  patient  dies,  or  coma  or  convulsions 
come  on,  and  close  the  scene. 

It  is  not  always,  however,  that  the  last  stage  of  croup  is  attended  by 
such  distressing  symptoms.  The  treatment  employed  may  seem  to  have 
mitigated  the  severity  of  the  disease ;  the  restlessness  may  give  place 
to  ease,  the  burning  skin  may  grow  moist,  the  respiration  may  become 
tranquil,  the  cough  loose  with  but  little  clangor  ;  expectoration  may  be 
easy,  and  a  wheezing,  attended  with  very  slight  croupy  sound  may  be 
the  only  indication  of  the  dangerous  disease  under  which  the  patient  is 
suffering.  This  apparent  amendment  may  continue  for  a  few  hours,  and 
then  be  succeeded,  without  any  assignable  cause,  by  the  return  of  all  the 
former  symptoms,  and  soon  be  followed  by  death ;  or,  the  mitigation  of 
the  disease  may  be  accompanied  with  great  drowsiness,  which,  however, 
does  not  excite  alarm,  since  it  is  very  naturally  attributed  to  the  exhaus- 
tion produced  partly  by  the  disease,  partly  by  the  remedies.  During 
sleep,  the  respiration  is  deep  and  tranquil,  like  that  of  a  person  in  a 
sound  slumber  ;  it  is,  indeed,  attended  by  a  kind  of  wheeze,  but  presents 
little  of  the  croupy  stridor ;  and  when  awake  the  child  is  quite  sensible, 
and  even  cheerful.  After  a  time,  however,  it  becomes  difficult  thoroughly 
to  rouse  him;  his  pulse  grows  more  rapid,  the  moisture  on  his  skin 
changes  almost  imperceptibly  to  a  cold  clammy  sweat,  and  convulsive 
twitchings  of  the  angles  of  the  mouth  occasionally  disturb  the  repose  of 
his  features.  Silently,  but  surely,  the  exudation  has  been  making  pro- 
gress, and  when  the  alarm  is  taken  it  is  too  late ;  the  stupor  deepens, 
and  the  child  dies  comatose,  or  rouses  only  to  spend  its  last  hours  in  the 
vain  struggle  for  breath,  and  embittered  by  all  the  painful  circumstances 
which  ordinarily  attend  the  suffocative  stage  of  croup. 

Auscultation  yields  us  information  in  cases  of  croup  with  reference  to 
two  important  points ;  namely,  the  amount  of  obstruction  to  the  entrance 
of  air  into  the  lungs,  and  the  extent  of  disease  of  the  air- tubes  or  sub 


RESULTS   OF   AUSCULTATION   IN   ITS   DIFFERENT   STAGES.  221 

stance  of  the  lungs  which  accompanies  it.  At  first,  air  is  heard  entering 
the  chest  freely,  and  unattended  by  any  morbid  sound  other  than  that 
stridor  which  is  produced  in  the  larynx.  If  the  lungs  should  continue 
unaffected,  no  other  morbid  sound  will  be  heard ;  but,  as  the  disease 
advances,  the  same  negative  results  will  be  obtained  from  auscultation 
as  are  yielded  by  it  in  cases  of  emphysema — a  feeble  respiratory  murmur 
belying  the  loud  resonance  on  percussion.  Often,  however,  respiration 
is  attended  from  the  commencement  with  the  sonorous  rhonchus  of  the 
first  stage  of  bronchitis,  though  masked  to  some  extent  by  the  croupy 
noise  in  the  trachea.  Even  in  cases  where  the  disease  is  originally  con- 
fined to  the  larynx  or  trachea,  inflammation  almost  always  extends  to 
the  bronchi ;  often,  also,  to  the  substance  of  the  lungs,  so  that  mucous 
or  subcrepitant  rale  generally  becomes  perceptible  during  its  course, 
often  attended  by  impaired  resonance  on  percussion  over  the  lower  part 
of  the  chest.  Air,  however,  may  enter  so  imperfectly  as  not  to  fill  the 
smaller  bronchi ;  and  these  sounds  may  be  quite  unperceived,  unless 
the  auscultator  listen  at  the  moment  when  the  child  makes  an  unusually 
deep  inspiration,  such  as  often  follows  a  fit  of  coughing.  The  pneumonia, 
too,  in  all  cases  that  I  have  observed,  was  double,  and  the  resonance 
consequently  nearly  equally  diminished  on  both  sides  of  the  chest. — 
Hence  the  importance  of  comparing  the  sound  elicited  by  percussion  of 
the  upper  with  that  given  out  by  the  lower  part  of  the  chest, — a  point 
to  which  you  will  remember  that  your  attention  has  already  been  called 
on  several  occasions. 

The  changes  in  the  tracheal  sound  which  attend  the  progress  of  the 
disease  may  be  traced  with  great  distinctness  by  applying  a  stethoscope 
to  the  larynx.  Some  writers  have  thought  that  they  recognised  in  its 
variations  the  indications  of  the  formation  of  false  membrane,  and  that 
they  also  afford  a  means  whereby  to  judge  of  its  extent.  I  believe  that 
usually  when  false  membrane  has  been  extensively  formed  in  the  larynx, 
the  tracheal  sound  becomes  less  stridulous  and  more  sibilant ;  but  I 
noticed  on  one  occasion  those  changes  in  the  tracheal  sound  which  are 
supposed  to  indicate  the  presence  of  a  very  extensive  deposit  of  false 
membrane,  although  no  false  membrane  was  either  expectorated  during 
the  patient's  lifetime,  or  discovered  in  the  inflamed  larynx  and  trachea 
after  her  death.  We  must  conclude,  therefore,  that  the  changes  in  the 
tracheal  sound  do  not  afford  absolutely  certain  evidence  of  the  existence 
of  false  membrane,  and  that  still  less  can  they  be  regarded  as  safe  cri- 
terions  of  its  extent. 

It  is  difficult  to  state  with  precision  the  duration  of  a  disease  such 
as  croup,  since  its  premonitory  symptoms  vary  greatly,  and  its  fatal 
termination  is  often  in  great  measure  due  to  the  concomitant  or  consecu- 
tive bronchitis  or  pneumonia.  When  the  laryngeal  affection  goes  on  to 
destroy  life,  it  is  seldom  that  more  than  forty-eight,  or  at  the  most 
seventy-two,  hours  elapse  from  the  full  developement  of  the  croupal 
symptoms  to  the  fatal  event ;  and,  allowing  the  ordinary  duration  of  the 
premonitory  stage  to  be  about  thirty-six  hours,  the  disease  will  be  found 
to  run  its  course  in  from  four  to  six  days.  Once  I  knew  death  to  take 
place  in  the  case  of  a  little  boy,  aged  4  years,  within  thirty-six  hours 


222  DURATION   OF   CROUP  PROGNOSIS. 

from  the  occurrence  of  the  first  croupal  symptoms;  but  no  other 
instance  of  equal  rapid  termination  of  the  disease  has  come  under  my 
own  observation.  Treatment  sometimes  partially  subdues  it;  but  it 
returns  and  the  relapse,  in  the  course  of  a  few  hours,  proves  fatal. — 
Now  and  then  the  acute  symptoms  subside,  and  the  disease  assumes  a 
chronic  character  ;  but  this  has  only  once  come  under  my  notice  in 
idiopathic  croup,  though  it  is  more  common  in  that  form  of  the  disease 
which  we  shall  have  hereafter  to  notice  as  constituting  a  serious  compli- 
cation of  measles. 

The  prognosis  of  croup  must  always  be  guarded,  and  is  generally 
unfavourable,  since  the  disease  is  unquestionably  one  of  the  most  dange- 
rous to  which  childhood  is  liable.  Much  depends  upon  the  patient 
being  seen  at  an  early  stage  of  the  disease  ;  and  the  prospect  of  recovery 
is  generally  very  small  if  no  treatment  should  have  been  adopted  until 
after  the  full  developement  of  the  symptoms.  The  presence  of  bronchitis 
and,  still  more,  of  pneumonia,  adds  greatly  to  the  dangers  of  the 
affection,  and  would  induce  us  to  form  a  very  unfavourable  opinion  of 
the  chances  of  recovery.  A  second  attack  of  croup  is  generally  less 
serious  than  the  first;  and  cases  in  which  catarrhal  symptoms  have 
preceded  the  seizure  for  several  days  are  more  amenable  to  treatment 
than  those  in  which  the  premonitory  stage  has  been  short,  or  altogether 
absent.  Diminution  of  the  dyspnoea  in  the  intervals  of  the  cough, — 
a  louder  and  looser  cough,  attended  with  expectoration  or  vomiting  of 
muco-purulent  matter,  intermingled  with  shreds  of  false  membrane, — 
a  less  suppressed  voice,  less  anxiety,  and  less  restlessness, — all  indicate 
that  the  disease  is  abating.  Much  caution,  however,  must  be  exercised 
in  drawing  a  favourable  conclusion  from  a  diminution  of  the  severity  of 
the  symptoms,  until  such  improvement  has  continued  for  twenty-four 
hours  at  least.  In  all  but  the  most  acute  cases  of  croup  the  remittent 
character  of  the  disease  is  very  apparent ;  and  it  is  well  to  bear  in  mind 
that  the  fatal  termination  usually  takes  place  with  extreme  rapidity, 
when  an  exacerbation  of  the  symptoms  follows  soon  after  a  manifest 
remission  of  their  intensity.1  It  can  scarcely  be  necessary  to  remind 
you  that  the  extinction  of  the  voice,  suppression  of  the  cough,  the 
change  from  stridulous  to  sibilant  breathing,  and  increased  difficulty  of 
respiration,  all  shew  death  to  be  surely  and  speedily  approaching. 

In  no  disease  is  the  prompt  employment  of  appropriate  treatment 
more  important  than  in  croup,  since  in  none  does  the  use  of  remedies 
sooner  become  unavailing.  Even  in  cases  where  the  attack  is  merely 
apprehended,  but  where  catarrh  exists,  attended  with  a  slight  ringing 
cough,  such  as  often  indicates  the  commencement  of  croup,  the  patient 
should  be  watched  most  sedulously,  and  visited  not  merely  by  day-time, 
but  also  late  in  the  evening  ;  and  attention  should  be  particularly  directed 
to  the  character  of  the  respiration  during  sleep  as  well  as  in  the  waking 
state.  The  child  should  at  once  be  placed  in  a  warm  bath,  be  confined 
to  bed,  be  placed  on  a  spare  diet,  and  should  take  an  emetic  of  ipecacu- 
anha and  antimony,  to   be  followed  by  some  mild  saline  medicine, 

1  "Mox  post  symptomatum  remissioncni  recidivantes,  brevi  ac  certa  morte  dein- 
untur."— Golis,  lib.  cit.  p.  164. 


TREATMENT   OF   CROUP.  223 

containing  slightly  nauseating  doses  of  antimonial  wine.1     At  the  same 

No.  13. 

1  R  Potassse  Bicarbonatis,  gr.  xl. 
Acidi  Citrici,  gr.  xx. 
Vin.  Ant.  Pot.-Tart.  giss. 
Vin.  Ipecac.  Tr^xx. 
Syr.  Limonum,  ^iiss. 

Aqua?,  ^iiss.     M.     giij.  3tia  vel  4ta  quaque  bora. 
For  a  child  two  years  old. 

time  the  air  which  the  child  breathes  should  be  both  warm  and  moist, 
the  temperature  of  the  room  being  steadily  kept  up  at  65°,  while  the 
moisture  of  the  air  is  easily  maintained,  by  a  kettle  boiling  on  the  fire, 
with  a  long  roll  of  paper  on  its  spout,  which  serves  to  direct  the  steam 
into  the  apartment-  These  simple  precautions,  useful  in  diminishing 
the  irritability  of  the  air-tubes  when  croup  is  merely  threatened,  are,  I 
need  scarcely  say,  of  still  greater  moment  when  the  disease  is  fully 
developed.  By  these  precautions,  which  should  be  observed  with 
especial  care  if  the  premonitory  symptoms  of  croup  appear  in  a  child 
who  has  previously  suffered  from  the  disease,  or  in  whose  family  a 
liability  to  it  exists,  you  may  often  succeed  in  warding  off  the  attack. 
A  far  more  energetic  plan  must  be  resorted  to  if  the  disease  set  in 
with  violence,  or  if  the  indications  of  its  approach  having  been  either 
overlooked  or  unchecked,  the  symptoms  should  have  attained  their  full 
development  before  the  patient  came  under  your  notice.  The  abstrac- 
tion of  blood,  and  the  administration  of  tartar  emetic,  are  the  two  mea- 
sures on  which  your  main  reliance  must  be  placed ;  and  you  must  bleed 
largely,  and  give  tartar  emetic  freely,  remembering  that  if  relief  do  not 
come  soon  it  will  not  come  at  all, — that  there  is  not  danger  only,  but 
death,  in  delay.  I  have  never  met  with  an  exception  to  the  rule  which 
prescribes  the  free  abstraction  of  blood  in  every  case  of  severe  idio- 
pathic croup,  when  seen  at  an  early  period,  and  before  the  purple  lips 
and  livid  countenance,  and  failing  pulse,  announce  the  long  continu- 
ance of  a  serious  obstacle  to  the  free  admission  of  air  into  the  lungs. 
Even  in  very  young  children  local  depletion  forms  in  these  cases  but  a 
poor  substitute  for  general  bleeding,  for  it  is  not  merely  the  abstraction 
of  a  certain  quantity  of  blood  that  is  needed,  but  its  removal  in  such  a 
manner  as  most  speedily  to  produce  an  effect  on  the  system.  Bleed- 
ing from  the  jugular  vein  is  preferable  under  these  circumstances  to 
venesection  in  the  arm,  since  the  latter  often  fails  in  children  under 
three  years  old ;  and  the  blood  never  flows  so  freely  as  when  taken 
from  the  jugular  vein.  It  is  not  easy  to  state  in  figures  the  exact 
quantity  to  be  abstracted,  since  the  child's  previous  health,  the  inten- 
sity of  the  symptoms,  and  the  effect  produced  by  the  flow  of  the  blood, 
must  all  be  taken  into  account  in  determining  when  to  stop.  Dr. 
Cheyne  says  "  The  removal  of  three  ounces  of  blood  from  a  child  be- 
tween one  and  two  years  of  age,  or  of  six  ounces  from  a  child  from  eight 
till  ten,  generally  appears  to  make  a  sufficient  impression  on  the  dis- 
ease ;"  and  this  is  a  sufficiently  near  approach  to  a  correct  estimate  of 


224  DEPLETION. 

what  is  usually  needed.  The  effect  of  free  venesection  is  often  very 
striking,  and  as  the  blood  flows,  the  respiration  may  be  seen  to  become 
notably  easier.  But  though  the  relief  thus  afforded  is  very  great,  it 
proves  but  temporary ;  and  unless  followed  by  other  remedies,  the 
symptoms  will  often  regain  their  former  intensity  in  the  course  of  four 
or  six  hours.  I  have  not  seen  any  instance  in  which  the  repetition  of 
general  bleeding  appeared  indicated,  but  many  of  you  will  probably 
meet  with  such  cases  in  the  country.  Local  depletion  I  have  occasionally 
employed  with  advantage  a  few  hours  after  the  general  bleeding  ;  but 
if  you  follow  up  the  first  loss  of  blood  by  the  free  employment  of  tartar 
emetic,  you  will  often  be  spared  the  necessity  for  further  depletion.  It 
has  been  recommended  that  leeches  should  be  applied  to  the  top  of  the 
sternum  rather  than  to  the  windpipe,  since  difficulty  may  be  experienced 
in  arresting  their  bleeding  if  applied  in  the  latter  situation,  as  children 
are  very  intolerant  of  pressure  in  that  neighbourhood.  The  caution  is 
worth  bearing  in  mind ;  but  if  you  superintend  the  application  of  the 
leeches  yourselves,  which  in  such  a  case  you  certainly  ought  to  do,  the 
advantage  of  drawing  the  blood  as  nearly  as  possible  from  the  affected 
part  will  more  than  make  up  for  the  risk  of  some  slight  difficulty  in 
stopping  its  flow. 

To  accomplish  any  real  good  by  means  of  the  tartar  emetic  it  must 
be  given  in  doses  of  an  eighth,  a  quarter,  or  half  a  grain  every  ten 
minutes  until  vomiting  is  produced ;  and  the  same  doses  should  after- 
wards be  continued  every  half  hour,  until  decided  and  permanent  relief 
has  been  afforded.  The  dose  that  at  first  caused  vomiting,  may,  after 
it  has  been  repeated  a  few  times,  cease  to  excite  it,  in  which  case  we 
must  increase  it,  and  not  rest  satisfied  with  tolerance  of  the  medicine 
having  been  established,  since  its  utility  appears  to  be  closely  connected 
with  its  emetic  power.  Nauseating  doses  of  antimony  have  not  seemed 
to  me  to  check  the  disease  so  surely,  while  they  cause  a  greater  de- 
pression of  the  system,  and  thus  mask  the  approach  of  the  fatal  event. 
A  striking  illustration  of  the  superiority  of  emetic  over  nauseating 
doses  of  medicine  is  given  by  M.  Valleix,*  who  states  that  in  thirty-one 
out  of  fifty-three  cases  of  true  croup,  ipecacuanha  and  antimony  were 
employed  in  full  doses  as  emetics,  and  of  these  thirty-one  cases  fifteen 
recovered  ;  while  of  the  twenty-two  cases  in  which  their  use  was  but 
sparingly  resorted  to,  only  one  recovered. 

If  after  antimony  has  been  thus  administered  for  four  or  six  hours, 
no  satisfactory  measure  of  improvement  should  have  appeared,  local 
depletion  may  be  resorted  to ;  or  possibly  a  repetition  of  general 
bleeding  may  in  some  cases  be  ventured  on.  If  the  croupal  symptoms, 
on  the  other  hand,  should  have  begun  to  abate,  the  antimony  may  be 
given  at  longer  intervals ;  but  you  cannot  be  too  much  on  your  guard 
against  being  misled  by  temporary  improvement,  and  abandoning  the 
medicine  too  soon.  Its  use  likewise  is  not  to  be  relinquished  by 
gradually  diminishing  the  dose  and  substituting  a  quantity  sufficient 
only  to  induce  nausea  for  that  which  caused  vomiting,  but  a  full  dose 
should  be  given  every  hour  or  two  hours,  instead  of  every  half  hour, 

1  Bulletin  G6n6ra\e  de  Thdrapeutique,  Oct,  1843,  p.  246. 


ADMINISTRATION   OF   MERCURY.  2LO 

and  if  amendment  continue,  the  interval  may  be  prolonged  to  three, 
four,  or  six  hours.  It  is  now,  after  the  severity  of  the  disease  has  been 
subdued  by  antimony,  that  the  time  has  come  for  the  administration  of 
calomel.  From  the  very  commencement  of  the  attack,  mercurial 
inunction  may  be  had  recourse  to  every  two  or  three  hours :  but  the 
action  of  mercurials  is  far  too  slow  to  overtake  a  disease  which  tends 
so  rapidly  to  a  fatal  issue.  At  this  period,  however,  calomel  seems  to 
have  a  two-fold  utility ;  it  counteracts  the  tendency  to  the  formation  of 
false  membrane  in  the  air-passages,  and  prevents  or  subdues  that 
inflammation  of  the  lungs  which  is  so  frequent  and  so  fatal  a  compli- 
cation of  the  disease.  I  usually  employ  it  in  doses  of  half  a  grain  or 
a  grain  in  children  from  two  to  five  years  old  every  hour  or  two  hours, 
in  combination  with  minute  doses  of  ipecacuanha,  but  interrupting  its 
use  at  intervals  in  order  to  give  an  antimonial  emetic.  The  appearance 
of  any  exacerbation  of  the  croupal  symptoms,  however,  would  lead  me 
at  once  to  discontinue  the  calomel,  and  to  return  to  the  emetic  employ- 
ment of  antimony. 

There  is,  however,  one  point  which  it  is  important  to  remember  in 
the  management  of  the  severer  cases  of  croup,  lest  you  fall  into  the 
error  of  over-treating  your  patient ;  an  error  not  less  hazardous  than 
the  opposite  one  of  too  great  inertness.  The  disease,  as  you  know, 
has  a  marked  tendency  to  exacerbations  and  remissions,  even  inde- 
pendently of  any  physical  change  in  the  condition  of  the  respiratory 
organs.  You  must  not,  therefore,  allow 'the  return  of  more  difficult 
breathing,  after  a  period  of  comparative  tranquillity,  to  lead  you  at 
once  to  the  inference  that  the  child  is  worse,  and  that  necessity  exists 
for  renewed  and  increased  activity  of  treatment.  It  is  very  possible 
that  the  increased  dyspnoea  may  be  merely  spasmodic ;  that  immersing 
the  child  in  a  hot  bath  will  give  immediate  and  most  signal  relief;  and 
that  if  you  auscultate  the  chest  afterwards  you  will  find  the  air  entering 
the  lungs  in  as  large  a  quantity  as  before,  and  unattended  by  any 
increase  of  morbid  sounds. 

The  administration  of  calomel  is  not  necessary  in  every  case  of  croup, 
for  when  seen  early  and  treated  with  due  activity,  its  symptoms  are 
sometimes  completely  removed  in  the  course  of  a  few  hours.  But 
though  we  may  sometimes  be  warranted  in  suspending  all  active 
treatment  for  a  season,  yet  we  must  watch  our  patient  with  most 
untiring  care  for  some  days  after  the  decline  of  the  acute  croupal 
symptoms,  and  at  each  visit,  our  attention  must  be  directed  to  the 
condition  of  the  lungs,  in  order  that  we  may  at  once  put  a  stop  at  its 
very  commencement  to  that  inflammation  of  the  smaller  bronchi  and  of 
the  pulmonary  substance  which  so  often  disappoints  the  fairest  pros- 
pects of  recovery.  Its  treatment  does  not  differ  from  that  of  ordinary 
bronchitis  or  pneumonia,  except  that  depletion  is  not  generally  indi- 
cated, and  that  it  not  infrequently  becomes  necessary  to  support  the 
patient's  strength,  even  from  a  very  early  period. 

Your  own  good  sense  will  suggest  to  you  the  care  and  watching  which 
are  required  during  convalescence  from  croup  ;  the  necessity  of  with- 
drawing your  remedies  cautiously,  and  of  awaiting  the  complete 
disappearance  of  all  hoarseness  and  cessation  of  all  cougb,  before  you 

15 


226  TREATMENT   OF   CROUP. 

allow  the  child  to  breathe  the  external  air.  In  cases  where  the 
peculiar  croupal  sound  continues  with  slight  cough,  long  after  every 
other  sign  of  mischief  about  the  larynx  has  subsided,  you  will  often 
find  it  of  service  to  paint  the  neighbourhood  of  the  windpipe  every  day 
with  the  Tincture  of  Iodine  ;  a  mild,  but  under  the  circumstances  very 
efficacious,  form  of  counter-irritation. 

It  still  remains  for  us  to  inquire  into  the  treatment  of  cases  in  which 
we  have  not  the  good  fortune  to  encounter  the  disease  at  its  outset,  but 
in  which  we  have  to  combat  it  when  it  has  already  reached  the 
second  stage. 

This  subject,  however,  must  be  reserved  for  our  next  lecture. 


LECTURE    XX. 

Croup  continued, — treatment  of  the  more  advanced  stages  of  the  disease — tracheotomy 
— the  difference  between  the  results  obtained  by  it  in  England  and  France,  and 
its  probable  cause — objections  to  its  performance — reasons  for  not  regarding  them  as 
conclusive. 

DiPHTHEEiTis,  or  Croup  with  affection  of  the  fauces, — less  frequent  and  less  marked  in 
this  country  than  in  France — its  symptoms  when  it  occurs  alone — oftener  follows 
some  other  disease,  especially  measles — its  symptoms — treatment  of  both  forms. 

Laryngitis  stridula,  or  Croup  with  predominance  of  spasmodic  symptoms — not  a 
distinct  disease,  but  results  from  constitutional  peculiarity — illustrative  case. 

Instances  of  spasmodic  cough  and  affection  of  larynx,  from  irritation  in  lungs — 
intestines — brain. 

In  the  last  lecture  we  were  occupied  with  the  consideration  of  the 
management  of  those  cases  of  croup  in  which  the  patient  is  seen  early, 
and  in  which  his  condition  warrants  the  employment  of  powerful  anti- 
phlogistic measures.  He  may,  however,  be  seen  too  late  for  such  means 
to  be  allowable,  or  they  may  have  been  tried  in  vain.  If  antimony 
cease  to  vomit,  or  if  it  be  rejected  immediately  and  without  effort,  the 
fluid  thrown  up  being  unmixed  with  phlegm  or  false  membrane,  while 
the  temperature  sinks,  the  lips  grow  more  livid,  the  pulse  becomes  more 
frequent  and  feeble,  and  the  paroxysms  of  dyspnoea  are  undiminished 
in  severity ;  or  if  the  respiration,  though  less  laborious,  be  attended 
with  a  sibilant  instead  of  a  stridulous  sound,  it  is  evident  that  by  con- 
tinuing the  medicine  we  may  destroy  the  patient,  but  shall  fail  to  cure 
the  disease.  A  totally  different  plan  of  treatment  must  at  once  be 
adopted,  though  with  but  slender  hope  of  success. 

An  attempt  must  be  made  to  arouse  the  child  from  the  state  of  col- 
lapse into  which  it  is  sinking,  by  placing  it  for  a  few  minutes  in  a  hot 
mustard  bath,  and  emetics  of  the  sulphate  of  copper  should  at  once  be 
administered.  The  sulphate  of  copper  has  been  considered  by  some 
writers  to  be  possessed  of  a  specific  influence  over  croup.  I  cannot, 
however,  take  this  view  of  its  action.  It  has  seemed  to  me  to  be  nothing 
more  than  an  emetic  of  great  power,  and  therefore  especially  applicable 
in  cases  where  considerable  depression  exists,  where  the  stomach  has 


TREATMENT   OF   THE   ADVANCED   STAGE   OP   CROUP.  227 

consequently  lost  much  of  its  irritability,  and  where  tartar  emetic  would 
probably  not  act  at  all,  or  if  it  did  would  be  injurious  from  its  depress- 
ing action.  Alum  has  been  recommended  under  similar  circumstances, 
and  I  dare  say  would  answer  equally  well,  though  perhaps  there  is 
some  advantage  in  the  smaller  bulk  of  the  sulphate  of  copper.1  I  am 
accustomed  to  give  it  dissolved  in  water  in  quarter  or  half-grain  doses 
every  quarter  of  an  hour  till  free  vomiting  has  been  produced,  but  have 
never  trusted  to  it  alone,  in  the  same  way  as  in  an  earlier  stage  of  the 
disease  I  am  used  to  rely  on  tartar  emetic.  I  employ  it  with  a  two- 
fold purpose:  first,  to  obtain  the  stimulant  action  of  an  emetic;  second, 
to  prevent  if  possible  the  accumulation  of  false  membrane  in  the  larynx. 
Hence,  if  the  child  seem  again  sinking  into  a  state  of  collapse,  or  if 
coma  appear  coming  on,  or  if  the  dyspnoea  become  much  aggravated, 
the  sulphate  of  copper  may  again  be  employed  to  induce  vomiting.  If, 
however,  in  these  cases,  or  in  others  in  which,  though  some  degree  of 
improvement  has  followed  the  previous  treatment,  yet  the  child  has 
been  much  reduced  by  it,  emetics  should  not  act,  I  would  not  advise 
you  to  attempt  to  compel  vomiting  by  irritating  the  fauces  or  other 
similar  proceedings.  On  one  occasion  I  saw  these  endeavours  followed, 
not  by  the  vomiting,  which  they  were  intended  to  excite,  but  by  general 
convulsions,  followed  by  a  comatose  condition,  in  which  death  took 
place  an  hour  and  a  half  afterwards.  Examination  of  the  body  dis- 
covered some  congestion  of  the  brain,  but  shewed  at  the  same  time  that 
the  affection  of  the  air-passages  had  not  reached  such  a  degree  as  to 
have  precluded  the  possibility  of  recovery,  and  that  the  patient's  death 
had  been  caused  not  by  the  disease,  but  rather  by  the  ill-judged 
employment  of  a  remedy. 

In  this  stage  of  croup  the  decoction  of  senega  is  a  medicine  of  great 
value,  and  may  be  given  in  combination  with  the  carbonate  of  ammonia 
and  tincture  of  squills,  every  two  hours.2  The  pungency  of  the  ammonia 
is  best  concealed  by  sweetening  the  medicine  with  treacle  or  coarse 
sugar,  and  mixing  it  with  about  a  third  of  milk;  and  in  this  form 
children  will  seldom  refuse  it.  No  other  remedy  or  combination  of 
remedies  has  appeared  to  me  to  be  so  useful  as  a  stimulant  expectorant 
in  the  advanced  stages  of  croup  or  bronchitis.  The  patient's  strength 
must  be  supported  by  beef-tea,  and  a  generally  nutritious  diet ;  and 
even  wine  may  be  indicated;  though  small,  indeed,  are  the  hopes  that 
remain  when  the  vital  powers  have  sunk  so  low  as  to  require  its  employ- 
ment. While  by  these  means  you  try  to  keep  your  patient  alive,  there 
is  still  one  remedy  that  you  may  use,  and  use  actively,  though  I  fear 
it  must  be  admitted  with  no  great  prospect  of  success.  You  employ 
mercury,  or  you  increase  the  dose  in  which  you  have  previously  been 
giving  it.  A  grain  of  calomel  may  be  given  every  hour  to  a  child  from 
two  to  three  years  old,  unless  the  existence  of  profuse  diarrhoea  should 

1  Alum  has  been  used  and  strenuously  recommended  under  these  circumstances  by 
Dr.  Meigs  of  Philadelphia  ;  and  the  experience  of  his  son,  Dr.  J  F.  Meigs,  as  recorded 
in  his  work  on  Diseases  of  Children,  seems  fully  to  bear  out  his  father's  recommendation. 
He  gives  a  teaspoonful  in  honey  or  syrup,  every  10  or  15  minutes,  till  free  vomiting  is 
produced. 

2  See  Formula  No.  12,  p.  190. 


228  COUNTER-IRRITATION — BRONCHOTOMY. 

contraindicate  its  use ;  while,  at  the  same  time,  a  drachm  of  strong 
mercurial  ointment  may  be  rubbed  into  the  thighs  every  two  hours.  If 
diarrhoea  be  present,  the  calomel  must  be  given  more  sparingly,  or 
even  altogether  omitted. 

Much  difference  of  opinion  prevails  among  writers  of  high  repute  as 
to  the  proper  time  for  employing  counter-irritation  in  cases  of  croup, 
and  still  more  as  to  the  part  to  which  this  counter-irritation  should  be 
applied.  I  believe  that  when  the  disease  has  been  checked  by  anti- 
phlogistic measures,  and  the  symptoms  have  lost  something  of  their 
severity,  much  good  is  done  by  the  application  of  blisteis  to  the  upper 
part  of  the  sternum.  But,  on  the  other  hand,  if  croup  have  reached 
an  advanced  stage,  unchecked  by  previous  remedies,  blisters  to  the 
sternum  have  seemed  to  me  nearly,  if  not  altogether,  useless  ;  while, 
from  the  application  of  a  large  blister  to  the  throat,  covering  the  larynx 
and  reaching  down  nearly  to  the  sternum,  I  have  often  observed  the 
paroxysms  of  dyspnoea  to  be  much  alleviated,  the  respiration  rendered' 
far  more  easy,  and  expectoration  for  the  first  time  accompanying  the 
cough.  In  any  case,  if  very  manifest  relief  were  not  observable  within 
six  hours  after  the  abstraction  of  blood  and  the  administration  of  anti- 
mony, while  further  depletion  did  not  appear  justifiable,  I  should  apply 
a  blister  to  the  throat.1 

It  was  to  be  expected  that  the  probable  utility  of  bronchotomy  in  cases 
of  croup  should  suggest  itself  to  the  earliest  observers  of  the  disease. 
For  many  years,  however,  after  it  was  first  advocated  on  theoretical 
grounds  by  Dr.  Home,  the  value  of  the  operation  was  not  put  to  the  test ; 
and  even  for  a  long  time  after  it  had  been  tried,  but  one  instance  was 
recorded  of  any  other  than  an  unsucccessful  result.2  In  the  year  1825, 
M.  Bretonneau,  of  Tours,  saved  the  life  of  a  little  girl  when  in  the  last 
stage  of  croup,  by  performing  tracheotomy  ;  and  the  operation  has  since 
then  been  performed  more  than  150  times,  and  rather  more  than  a  fourth 
of  the  patients  who  underwent  it  recovered.  By  far  the  greater  number 
of  these  successful  cases  occurred  in  France,  while  in  England  the  result 
of  almost  every  instance  of  the  performance  of  tracheotomy  in  cases  of 
croup  has  been  so  unfavourable,  that  the  operation  is  scarcely  looked 
on  as  a  justifiable  proceeding.  The  great  discrepancy  of  opinion  between 
French  and  English  practitioners,  with  reference  to  the  value  of  tracheo- 
tomy in  croup,  is  without  doubt,  in  a  great  measure  due  to  the  very 
different  character  which  the  disease  presents  in  the  two  countries.  In 
France,  croupal  symptoms  are  induced  in  the  majority  of  cases  by  the 
extension  to  the  larynx  of  false  membrane  originally  deposited  on  the 
fauces  and  soft  palate,  while  the  windpipe  itself  is  comparatively  seldom 
in  a  state  of  active  inflammation,  often  altogether  unaffected ;  and  the 

1  This  opinion  being  opposed  to  that  of  men  such  as  Dr.  Stokes  and  Mr.  Porter,  I 
feel  it  necessary  to  appeal  in  support  of  it  to  the  authority  of  Golis,  lib.  cit.  p.  118,  and 
Albers,  De  Tracheitide  Infantum,  p.  127  ;  and  not  to  rest  it  solely  on  the  results  of  my 
own  experience. 

2  In  this  case,  the  operation  was  performed  in  the  year  1782  by  the  late  Mr.  Andre, 
of  London,  on  a  little  girl  live  years  old.  The  particulars  are  related  in  a  dissertation, 
published  at  Leyden  in  1786,  by  Dr.  T.  White,  whence  they  are  extracted  by  Dr.  Fai-re, 
and  appended  as  a  note  to  a  paper  of  his  on  Croup,  at  page  o38  of  vol.  iii.  of  the 
Medico-Chirurgical  Transactions. 


TRACHEOTOMY  IN   CROUP.  229 

bronchitis  and  pneumonia,  which  in  this  country  so  often  and  so  seriously 
complicate  the  disease,  are  there  of  less  common  occurrence.  In  esti- 
mating the  results  of  tracheotomy  in  France,  it  must  likewise  be  borne 
in  mind  that  in  many  instances  the  operation  was  performed  on  patients 
whose  disease  would  probably  have  been  amenable  to  other  treatment, 
and  that  in  some  cases  the  trachea  was  opened  without  the  previous 
adoption  of  any  treatment  whatever,  and  quite  in  the  early  stage  of  the 
affection.1  But  though  we  cannot  infer  that  all  the  patients  on  whom 
tracheotomy  was  performed  would  have  died  if  the  operation  had  not 
been  resorted  to,  these  cases  of  premature  tracheotomy  at  least  prove  the 
operation  to  be  of  itself  unattended  with  very  serious  danger ;  while  it  is 
quite  conceivable  that  the  relief  afforded  by  it  to  that  spasmodic  action 
of  the  muscles  of  the  glottis,  which  endangers  the  patient's  life  more 
than  the  mere  extent  of  false  membrane  in  the  air-passages,  may  contri- 
bute, in  a  most  important  degree,  to  arrest  the  advances  of  the  disease. 
But  whatever  might  be  the  result  of  the  very  early  performance  of 
tracheotomy,  such  a  proceeding  would  be  practicable  only  in  a  hospital ; 
and  we  must  base  our  conclusions,  with  reference  to  the  operation,  on  a 
due  consideration  of  the  circumstances  under  which  alone  we  are  likely 
to  have  the  opportunity  of  performing  it.  "  There  is,"  as  Dr.  Stokes2 
has  truly  observed,  "  always  that  kind  of  feeling  connected  with  a  surgical 
operation  in  acute  diseases,  which  prevents  its  being  proposed,  assented 
to,  or  performed,  unless  under  nearly  desperate  circumstances,  and  when 
all  other  means  have  failed.  In  the  case  before  us,  the  operation  is  per- 
formed at  a  time  when  the  situation  of  the  patient  is  the  worst  possible 
for  success;  when  the  nervous  system  has  been  profoundly  injured,  and 
the  lungs,  even  though  no  primary  complication  may  have  existed,  have 
become  extensively  congested."  Among  my-patients  at  the  Children's 
Dispensary,  I  have  never  had  recourse  to  the  operation ;  partly  for  the 
reasons  stated  by  Dr.  Stokes,  partly  because  it  would  have  been  impos- 
sible in  the  houses  of  the  poor  to  command  that  constant  attention  and 
minute  care  which  are  absolutely  essential  to  the  success  of  tracheotomy, 
even  when  everything  in  the  patient's  condition  concurs  to  warrant  its 
performance.  Recently,  Mr.  Arnott  performed  tracheotomy,  at  my 
request,  on  a  boy  aged  twenty-one  months,  who  was  admitted  into  the 
Middlesex  Hospital  in  the  last  stage  of  croup,  which  had  succeeded  to 
measles,  and  which  had  been  allowed  to  advance  without  any  remedy 
being  employed  to  check  it.  In  this  instance  life  was  prolonged  for  forty 
hours  after  the  operation,  and  the  ingress  and  egress  of  air  through  the 
canula  continued  free  to  the  last ;  but  the  child's  pulse  began  to  grow 
more  frequent  and  feeble  after  the  lapse  of  little  more  than  twelve  hours, 
and  his  respiration  became  at  the  same  time  hurried  and  laborious, 
and  continued  increasingly  so  until  death  took  place.  This  being  the 
only  instance  in  which  I  have  had  the  windpipe  opened  for  the  relief 
of  the  symptoms  of  croup,  it  is  not  in  my  power  to  lay  down  any 

1  In  illustration  of  this  fact  two  cases  may  be  noticed,  recorded  in  the  Journal  de  la 
Societe  M6dicale  d'Inde  et  Loire,  extracted  and  commented  on  in  the  Bull.  Gen.  de 
Tiierapeutique,  October,  1842. 

2  On  Diseases  of  the  Chest,  8vo.  p.  220.     Dublin,  1837. 


230  ARGUMENTS   AGAINST   THE   OPERATION. 

definite  rules  with  reference  to  the  time  or  manner  of  performing  the 
operation. 

But  though  I  have  had  almost  no  experience  of  tracheotomy  in  croup, 
yet  it  is  impossible  to  have  closely  watched  many  cases  of  that  disease 
without  thinking  much  and  anxiously  upon  the  question  of  performing 
an  operation  for  its  relief.     Among  the  arguments  against  it,  there  are 
two  to  which  the  chief  importance  has  been  attached.     One  of  these  is 
founded  on  a  statement  of  Dr.  Cheyne's  that  three-eighths  of  the  aper- 
ture of  the  larynx  have  been  found  free  in  fatal  cases  of  croup,  and  that 
consequently  there  must  have  existed  during  life  room  enough  for  the 
entrance  of  air.  The  other  is  derived  from  the  condition  of  the  bronchi, 
which,  while  comparatively  seldom  free  from  disease  before  the  operation, 
generally,  as  is  alleged,  become  the  seat  of  increased  and  more  rapidly 
fatal  inflammation  after  its  performance.     With  reference  to  the  former 
of  these  arguments,  however,  I  apprehend  that  bronchotomy  is  not  per- 
formed merely  on  the  mechanical  principle  of  removing  from  the  windpipe 
a  quantity  of  matter  which  prevents  the  entrance  of  air  into  the  lungs  ; 
but  that  it  is  done  rather  to  obviate  the  dangers  of  that  spasm  of  the 
glottis  which  the  inflammation  occasions,  and  which  will  not  cease  until 
either  the  inflammation   is  subdued,  or  the   spasm  relaxes   with  the 
approach  of  death.     Even  the  narrow  opening  made  into  the  trachea — 
often  much  narrower  than  the  aperture  of  the  larynx,  though  diminished 
by  swelling  or  encroached  on  by  false  membrane — suffices  for  a  time,  at 
least,  to  admit  all  the  air  which  the  patient  needs,  and  the  dyspnoea  is 
relieved.     The  inflamed  larynx  is  now  at  rest,  while  the  air  entering 
continuously,  and  without  effort,  duly  oxygenates  the  blood ;  and  the 
child  is  thus  placed  in  a  condition  in  which  all  remedial  agents  would 
seem  much  more  likely  to  tell  upon  it,  than  when  it  was  in  a  state  of 
impending  suffocation.     But  then  this  promise  of  amendment  too  often 
is  but  delusive  :  the  relief  is  of  only  short  duration  ;  the  breathing  once 
more  becomes  difficult,  and  death  takes  place  under  symptoms  of  the 
same  kind  as  existed  before  the  operation,  though  attended  with  rather  less 
distress.     A  measure  of  euthanasia,  then,  is  all  that  in  many  cases  is 
obtained  by  tracheotomy ;  while,  in  the  opinion  of  many,  the  previous 
bronchitis  is  much  increased  by  its  performance,  and  the  patient's  death 
thus  accelerated.  Last  year,  however,  when  conversing  with  M.  Trousseau, 
at  Paris,  on  the  subject  of  tracheotomy,  he  suggested  another  reason  for 
the  relapse  which  so  generally  follows  even  the  most  encouraging  tem- 
porary improvement.    Tracheotomy  fails,  in  his  opinion,  in  great  measure 
because  the  opening  made  into  the   air  passages  is  too  small ;  air  is 
admitted  enough  to  afford  temporary  relief,  but  not  enough  for  the 
permanent  discharge  of  the  functions  of  the  organism  :  the  return  of 
hurried  breathing,  the  reappearance  of  the  livid  hue  of  the  surface, 
betoken  the  imperfect  depuration  of  the  blood.       Take  a  quill,  and 
closing  your  nostrils,  endeavour  to  breathe  entirely  through  it :  at  first 
you  breathe  easily  enough,  but  soon  your  respiration  becomes  laborious  ; 
and  at  length  you  are  fain  to  throw  away  the  quill,  and  with  open  mouth 
once  more  to  fill  your  lungs  completely.     Now,  precisely  this,  says  M. 
Trousseau,  is  what  happens  when  an  opening  of  inadequate  size  is  made 
into  the  trachea  ;  air  enters  readily,  and  without  the  interruption  which 


TRACHEOTOMY  IN   CROUP — ARGUMENTS   AGAINST  IT.  231 

the  spasm  of  the  glottis  occasioned;  but  it  does  not  enter  in  sufficient 
quantity,  and  hence  the  return  of  the  symptoms,  and  the  patient's  death. 
Acting  on  this  principle,  he  always  makes  a  much  larger  opening  into 
the  trachea,  and  introduces  a  much  larger  canula,  than  the  majority  of 
surgeons;  and  I  mention  his  opinions  and  practice,  because  I  think  they 
well  deserve  your  consideration. 

But,  now,  with  reference  to  the  second  objection, — the  uncertainty  of 
the  extent  to  which  inflammation  of  the  air-tubes,  with  possible  forma- 
tion of  false  membrane,  have  already  extended,  and  the  dangers  of 
aggravating  the  already  existing  bronchitis.  It  is  not  possible,  I  believe, 
to  determine  during  life  the  extent  to  which  false  membrane  may  have 
reached,  nor  at  all  easy  to  estimate  the  amount  of  bronchitis  ;  while, 
against  the  risk  of  aggravating  it,  by  tracheotomy,  we  must  weigh  on 
the  other  hand  the  evils  of  spasm  of  the  glottis,  and  the  effects  of 
unaerated  blood  circulating  through  the  vessels,  if  we  leave  the  case 
alone.  Moreover,  while  M.  Trousseau's  explanation  of  the  return  of 
dyspnoea  after  the  operation  may  be  received  as  accounting  for  a  part 
at  least  of  what  has  generally  been  attributed  altogether  to  the  bronchi- 
tis, it  must  not  be  forgotten  that  in  the  vast  majority  of  cases  the  delicate 
mucous  membrane  of  the  bronchi  has  been  exposed  to  immediate  contact 
with  the  cold  air  of  the  ward  of  a  hospital,  or  of  a  large  chamber, — a 
want  of  precaution  to  which  it  is  probably  not  unfair  to  attribute  a 
large  share  in  the  excitement  or  aggravation  of  the  secondary  bronchial 
inflammation. 

It  appears  to  me  to  be  worth  consideration,  how  far  the  careful 
regulation  of  the  temperature  of  the  apartment,  and  of  the  condition  as 
to  heat  and  moisture  of  the  air  respired  by  the  patient — to  the  import- 
ance of  which,  even  in  the  early  stages  of  the  disease,  I  have  already 
referred — might  diminish  the  hazard  of  bronchitis  after  the  operation. 
And,  secondly,  it  may  merit  inquiry  whether  there  be  any  difference  to 
be  expected  between  the  result  of  tracheotomy  in  cases  of  sthenic  croup, 
such  as  formed  the  basis  of  Dr.  Cheyne's  observations,  in  which  false 
membrane  was  very  extensively  deposited, — and  in  cases  of  a  more 
asthenic  character,  such  as  the  chief  of  those  were  that  came  under  my 
notice  among  the  poor  in  London,  in  which  the  deposit  of  false  mem- 
brane was  very  limited,  and  the  larynx  was  the  chief,  sometimes  the 
exclusive,  seat  of  the  disease. 

Perhaps,  now,  I  have  said  too  much  upon  this  subject,  seeing  that  I 
have  been  dealing  rather  with  theories  than  facts, — suggesting  doubts 
and  propounding  questions,  rather  than  laying  down  positive  rules; 
but  yet  I  thought  it  might  not  be  useless  if  I  stated  to  you  the  circum- 
stances that  make  me  hesitate  in  expressing  a  decided  opinion  against 
tracheotomy,  and  that  prevent  me  from  joining  at  present  in  the  un- 
qualified condemnation  of  the  operation  in  cases  of  croup,  which  has 
been  pronounced  by  the  greater  number  and  the  most  weighty  of 
English  authorities. 

I  have  endeavoured  hitherto  to  direct  your  attention  more  especially 
to  that  form  of  croup  which  is  of  most  frequent  occurrence  in  this 
country,  and  in  which  the  affection  of  the  air-tubes  is  a  primary  idio- 
pathic disease,  calling  for  active  antiphlogistic  treatment.     There  is, 


232  DIPHTHERITIS. 

however,  another  form  of  the  disease,  in  which  the  laryngeal  affection 
is  connected  with  inflammation  of  the  tonsils,  soft  palate,  and  fauces, 
and  the  deposit  of  false  membrane  upon  them ;  and  in  many  of  these 
cases  the  affection  of  the  air-passages  is  evidently  a  secondary  occur- 
rence. The  symptoms  attending  this  variety  of  croup  generally  present 
more  or  less  of  an  asthenic  character ;  and  corresponding  modifications 
must  he  made  in  the  treatment.  In  England  this  form  of  croup  is  com- 
paratively rare ;  when  it  does  occur,  it  is  in  crowded  cities  much  oftener 
than  in  the  country.  'The  influence  of  unfavourable  hygienic  conditions 
in  predisposing  to  it  is  well  illustrated  by  the  statement  of  M.  Guer- 
sent,  that  the  number  of  croup  cases  in  the  H6pital  des  Enfans  Malades 
has  become  greatly  diminished  since  the  wards  have  been  less  crowded 
with  patients,  and  since  other  means  have  been  adopted  calculated  to 
promote  the  health  of  the  inmates.  Another  strong  proof  of  the  influ- 
ence of  causes  unfavourable  to  health  in  inducing  some  varieties  of 
croup,  is  afforded  by  a  further  statement  of  the  same  writer,  that  the 
greater  number  of  cases  of  croup  in  the  Parisian  hospitals  have  super- 
vened in  patients  who  were  already  in  those  institutions  for  the  cure  of 
other  diseases. 

In  country  districts,  unfavourable  influences  of  a  different  kind  seem 
to  predispose  to  its  occurrence.  It  is  in  those  regions  of  France  which 
are  damp  and  ill-drained  that  it  presents  itself  in  its  most  aggravated 
forms,  and  there,  has  not  infrequently  assumed  an  epidemic  character, 
and  proved  extremely  fatal.  In  several  instances  such  epidemics  have 
broken  out  on  the  subsidence  of  an  inundation ;  but  at  other  times  it 
has  not  been  possible  to  assign  any  reason  for  the  sudden  appearance 
of  the  disease  in  an  epidemic  form  in  neighbourhoods  where  for  many 
years  it  had  been  unknown. 

In  this  country  it  seldom,  if  ever,  assumes  those  formidable  charac- 
ters which  have  often  marked  it  on  the  Continent,  where  the  inflamma- 
tion of  the  tonsils  and  pharynx  have  been  very  severe,  and  the  forma- 
tion of  false  membrane  has  not  been  limited  to  the  fauces,  but  has 
occupied  a  great  part  of  the  mouth,  and  reached  far  down  into  the 
pharynx,  as  well  as  extending  upwards  into  the  nostrils.  I  cannot  at 
all  account  for  this  difference  between  the  disease  in  the  two  countries ; 
but  the  mere  extent  of  the  false  membrane  does  not  seem  to  me  to 
furnish  any  ground  for  supposing  there  be  an  essential  difference 
between  the  affection  described  under  the  name  of  diphtheritis  by  M. 
Bretonneau,  and  other  French  writers,  and  that  in  which,  with  a  much 
more  limited  deposit  of  false  membrane,  there  has  yet  seemed  to  be  the 
same  connection  between  the  disease  of  the  throat  and  the  air-passages. 

This  form  of  croup  has  come  under  my  notice  under  two  different 
conditions, — either  as  an  idiopathic  affection,  or  as  a  complication  of 
some  other  malady ;  the  latter  much  more  frequently  than  the  former. 
In  those  cases  where  it  has  appeared  as  an  idiopathic  affection,  slight 
febrile  disturbance,  and  general  disorder  of  the  health,  have  usually 
preceded  the  local  symptoms  for  some  days.  By  degrees,  slight  cough 
comes  on,  often  associated  with  catarrhal  symptoms,  and  attended  with 
considerable  drowsiness  and  heaviness  of  the  head,  and  sometimes  with 
slight  difficulty  of  deglutition.     The  cough   next   assumes   the   loud 


DIPIITnERITIS   SOMETIMES   AN   IDIOPATHIC   AFFECTION.  233 

clangose  character  of  croup,  and  stridor  becomes  perceptible  with  the 
respiration.  If  the  throat  be  examined,  the  fauces,  soft  palate,  and 
tonsils,  will  usually  be  found  either  universally  red,  or  streaked  and 
spotted  of  a  dark  red  colour.  This  condition  is  generally  best  marked 
on  the  tonsils,  the  under  part  of  the  velum,  and  the  uvula,  and  is  in 
most  instances  attended  with  but  little  tumefaction.  Specks  of  false 
membrane,  of  a  dead  white  or  greyish-white  colour,  next  appear  on  the 
inflamed  surfaces.  I  have  seldom  seen  these  deposits  of  false  mem- 
brane become  confluent,  and  never  found  them  extend  up  into  the 
mouth,  even  though  the  life  of  the  patient  had  been  seriously  endan- 
gered by  their  extension  to  the  larynx,  while  in  many  instances  the 
affection  of  the  throat  maybe  altogether  overlooked  if  care  be  not  taken 
to  depress  the  root  of  the  tongue  sufficiently  to  obtain  a  thoroughly 
good  view  of  the  fauces.  When  once  the  larynx  has  become  affected, 
the  symptoms  are  in  the  main  the  same  as  attend  on  the  other  form  of 
croup,  but  there  is  less  of  that  constitutional  reaction  which  we  observe 
in  acute  inflammation  of  important  organs.  The  fever  generally  pre- 
sents throughout  much  of  an  adynamic  character ;  the  drowsiness  is 
often  very  considerable ;  and,  if  the  case  be  neglected,  the  fatal  termi- 
nation may  come  on  very  speedily,  without  being  ushered  in  by  that 
urgent  dyspnoea  and  those  violent  efforts  to  obtain  air  which  attend 
most  cases  of  cynanche  trachealis.  On  the  other  hand,  these  cases 
occasionally  run  a  somewhat  chronic  course.  The  employment  of 
emetics  having  detached^  the  false  membrane,  and  the  local  application 
of  caustics  having  for  a  time  prevented  their  reproduction,  the  croupal 
symptoms  diminish  or  altogether  disappear;  but  a  premature  suspen- 
sion of  the  treatment  is  soon  succeeded  by  a  return  of  the  dangerous 
symptoms  of  the  disease ;  and  hence  in  this,  not  less  than  in  the  other 
form  of  croup,  it  behooves  us  to  be  most  sedulously  on  the  watch  for 
any  indications  of  returning  mischief. 

It  is  not  as  an  idiopathic  affection  that  this  form  of  croup  has  come 
most  frequently  under  my  notice,  but  as  a  most  dangerous  complication 
of  some  other  disease,  almost  always  of  measles.  Under  these  circum- 
stances it  frequently  disappoints  the  most  well-founded  hopes  of  our 
patient's  recovery ;  sometimes  running  its  course  very  rapidly,  and  at 
other  times  so  insidiously  that  nothing  but  the  greatest  care  will  secure 
us  against  overlooking  this  most  fatal  malady. 

This  variety  of  croup  seldom  begins  until  the  eruption  of  measles  is 
on  the  decline,  or  the  process  of  desquamation  has  commenced.  Its 
occurrence  is  most  frequent  from  the  third  to  the  sixth  day  from  the 
appearance  of  the  eruption,  but  it  often  occurs  at  a  later,  than  at  an 
earlier  period.  It  is  sometimes  attended  with  well-marked  svmptoms 
from  the  very  first,  but  it  often  happens  that  the  character  of  the 
disease  is  masked,  and  its  course  insidious,  and  that  the  degree  of 
suffering  during  life  affords  no  correct  index  to  the  amount  of  mischief 
which  may  be  revealed  by  a  dissection  after  death.  Of  itself,  it  is 
highly  dangerous,  and  its  hazard  is  increased  by  the  frequent  coex- 
istence with  it  of  inflammation  of  the  lungs,  which  serves  moreover  to 
throw  the  symptoms  of  croup  into  the  shade.  When  the  laryngeal 
affection  comes  on  three  or  four  days  after  the  appearance  of  measles, 


234  DIPHTHERITIS   AS   A   COMPLICATION   OF   MEASLES. 

its  presence  is  usually  betokened  by  much  more  obvious  symptoms  than 
when  it  occurs  after  the  lapse  of  a  longer  period  from  the  febrile  attack. 
Sometimes,  however,  it  develops  itself  unnoticed,  simultaneously  with 
the  measles,  and  causes  a  fatal  issue  when  the  medical  attendant  is 
least  prepared  to  expect  it.  The  child  in  such  cases  is  evidently  more 
seriously  ill  than  can  be  accounted  for  by  the  mere  existence  of 
measles  ;  but  he  makes  no  definite  complaint,  neither  are  there  any 
obvious  indications  of  the  special  suffering  of  any  particular  organ. 
There  are  considerable  drowsiness,  disinclination  to  swallow,  and  reluc- 
tance to  speak  ;  but  the  cough  may  be  very  slight,  and  the  respira- 
tion free  from  distinct  croupy  stridor,  while  the  child  speaks  in  so  low 
a  tone  that  it  is  almost  impossible  to  appreciate  any  alteration  of  the 
voice.  Under  such  circumstances,  the  most  careful  observation  is 
needed  to  avoid  error.  The  loss  of  voice  should  of  itself  direct  atten- 
tion to  the  state  of  the  larynx ;  the  cry  should  be  listened  to  atten- 
tively ;  pressure  should  be  made  on  the  larynx,  to  ascertain  whether 
much  tenderness  exists,  and  examination  of  the  fauces  should  never  be 
neglected. 

But  little  less  obscure,  and  of  much  more  frequent  occurrence,  are 
those  instances  in  which  the  laryngeal  affection  attends  the  process  of 
desquamation.  Recovery  up  to  a  certain  point  had  probably  gone  on 
well,  when,  sometimes  with,  sometimes  without  an  increase  of  the 
cough  and  morbillous  catarrh,  the  febrile  symptoms  become  exacerbated, 
and  the  child  droops  again,  apparently  without  any  adequate  cause. 
Sometimes  a  loud  sonorous  cough,  succeeded  or  accompanied  by  altera- 
tion of  the  respiratory  sounds,  betrays  the  nature  of  the  disease  ;  but 
at  other  times  there  are  no  symptoms  besides  unusual  drowsiness, 
reluctance  to  speak,  or  alteration  in  the  tone  of  the  voice,  with  disin- 
clination to  swallow,  or  difficulty  in  the  act  of  deglutition.  In  many 
instances  deglutition  is  scarcely  at  all  impeded ;  and  I  remember  only 
one  case  in  which  the  difficulty  of  swallowing  was  so  great  that  the 
fluids  returned  by  the  nose.  But  even  though  these  symptoms  be  but 
slight,  it  will  usually  be  observed,  on  examining  the  mouth,  that  the 
gums  have  a  spongy  appearance,  or  are  actually  ulcerated  ;  that  the 
tongue  is  preternaturally  red  and  raw,  and  that  small  aphthous  ulcers 
have  formed  upon  its  edges,  and  on  the  lining  membrane  of  the  mouth. 
The  soft  palate  will  usually  be  seen  to  be  red  and  swollen,  and  specks 
of  false  membrane  will  be  observed  on  the  velum  or  tonsils.  In  such 
a  case,  if  it  terminate  fatally,  the  duration  of  life  is  very  variable ; 
though  the  disease,  for  the  most  part,  runs  a  somewhat  chronic  course. 
The  child's  strength  declines  daily,  and  emaciation  makes  rapid  pro- 
gress ;  yet  no  acute  symptoms  appear.  There  is  great  restlessness, 
and  no  posture  seems  easy  to  the  child  ;  or  else  it  sits  constantly 
upright  in  bed,  distress  and  dyspnoea  following  any  attempt  to  place 
it  in  the  recumbent  position.  The  alteration  of  the  voice  is  succeeded 
by  complete  aphonia,  the  frequent  hacking  cough  which  had  previously 
caused  much  annoyance,  ceases  altogether  ;  and  although  evidently 
thirsty,  the  child  often  refuses  drink,  or  swallows  with  difficulty. 
Diarrhoea,  or  pneumonia,  usually  supervenes,  and  hastens  death,  though 
in  some  instances  exacerbation  of  the  croupal  symptoms,  coupled  with 


MORBID   APPEARANCES — TREATMENT.  235 

the  increasing  weakness  of  the  child,  are  the  only  causes  of  the  fatal 
termination. 

On  examining  after  death  the  bodies  of  children  who  have  died  of 
this  affection,  not  only  is  the  mucous  membrane  of  the  mouth  found 
inflamed  and  ulcerated,  but  the  soft  palate,  fauces,  epiglottis,  and  the 
upper  part  of  the  pharynx,  are  seen  to  be  more  or  less  intensely  con- 
gested, and  coated  more  or  less  extensively  with  false  membrane. 
Once  I  observed  false  membrane  to  have  reached  from  the  pharynx  for 
a  short  distance  into  the  oesophagus ;  and  on  another  occasion  I  found 
the  oesophagus  lined  by  a  complete  tube  of  false  membrane,  which  had 
extended  to  within  an  inch  of  the  cardiac  orifice  of  the  stomach  ;  but 
I  have  never  seen  the  interior  of  that  viscus  occupied  by  a  similar  pro- 
duction, though  that  would  seem,  according  to  the  experience  of  French 
writers,  not  to  be  a  very  unusual  occurrence.  The  epiglottis  is  often 
ulcerated  on  both  its  surfaces,  and  partially  coated  with  false  mem- 
brane ;  and  the  mucous  membrane  of  the  larynx  is  generally  eroded  by 
numerous  small  ulcerations,  as  well  as  covered  with  a  similar  deposit. 
I  have  in  no  instance  observed  false  membrane  extending  below  the 
larynx ;  and  although  the  trachea  is  usually  congested,  sometimes 
intensely  so,  yet  this  is  by  no  means  of  invariable  occurrence.  Bron- 
chitis and  pneumonia,  especially  the  latter,  are  frequent  complications 
of  this  affection. 

Under  whatever  circumstances  this  form  of  croup  may  occur, — 
whether  as  an  idiopathic  malady,  or  as  a  sequela  of  measles  or  of  some 
other  disease, — it  is  generally  attended  with  so  great  a  depression  of 
the  vital  powers  as  to  contraindicate  the  employment  of  active  anti- 
phlogistic treatment.  When  it  occurs  as  an  idiopathic  affection,  I  have 
occasionally  applied  leeches  to  the  throat  if  there  was  much  tenderness 
about  the  larynx,  or  if  the  croupy  symptoms  had  early  acquired  considera- 
ble intensity  ;  but  the  two  means  on  which  I  place  my  chief  reliance  are  the 
careful  and  repeated  cauterization  of  the  fauces,  and  the  employment 
of  emetics.  If  the  deposit  of  false  membrane  be  extensive  or  the 
ulcerations  about  the  tonsils  present  anything  of  a  sloughy  character, 
the  strong  hydrochloric  acid,  diluted  with  twice  or  thrice  the  quantity  of 
honey,  is  the  best  application  to  the  fauces.  In  most  instances,  how- 
ever, a  solution  of  a  scruple  of  nitrate  of  silver  in  an  ounce  of  distilled 
water,  applied  by  means  of  a  sponge  or  a  piece  of  soft  rag  fastened  on 
a  small  portion  of  whalebone,  answers  every  purpose.  A  probang 
contrived  by  Dr.  Horace  Green,  of  New  York,1  the  sponge  attached  to 
which  is  sufficiently  small  to  enter  the  glottis  of  the  child,  answers 
extremely  well  for  this  purpose.  By  means  of  it  he  has  applied  a 
solution  of  9ij.  of  Argent.  Nitrat.  dissolved  in  an  ounce  of  water,  not 
merely  to  the  back  of  the  throat  and  the  neighbourhood  of  the  glottis,  as 
many  French  physicians  have  done  before  him,  but  also  carries  the 
sponge  into  the  interior  of  the  larynx  itself.     This  proceeding,  too, 

1  Observations  on  the  Pathology  of  Croup,  &c.,  12mo.  New  York,  1849.  The 
adoption  of  somewhat  similar  proceedings  by  MM.  Bretonneau,  Trousseau,  and 
Gerouard,  does  not  seem  to  me  sufficient  to  justify  the  very  grave  charge  of  plagiarism 
brought  against  Dr.  Green  by  one  of  his  countrymen,  in  the  American  Journal  of 
Medical  Science,  Jan.  18-49. 


236  TREATMENT   OP   DIPHTHERITIS. 

repeated  every  two  to  every  six  hours,  according  to  the  urgency  of  the 
case,  has  been  followed  in  some  apparently  desperate  cases  by  the 
patient's  recovery.  I  have  employed  it  but  once,  though  that  case 
quite  satisfied  me  of  the  possibility  of  cauterizing  the  interior  of  the 
larynx,  and  even  of  the  absence  of  any  considerable  difficulty  in 
accomplishing  it.  The  case  was  in  many  respects  an  unfavourable  one, 
and  I  cannot  say  that  the  fatal  termination  which  took  place  within 
24  hours  from  the  first  well-marked  croupal  symptom  was  at  all 
retarded  by  it.  It  was  practised  twice  ;  the  child  having  been  very 
freely  depleted  within  six  hours  from  the  commencement  of  the  disease, 
but  without  any  improvement.  The  first  cauterization  did  not  produce 
much  effect ;  the  second,  two  hours  afterwards,  was  followed  by  marked 
relief  to  the  respiration,  and  by  restoration  of  a  clear  instead  of  the 
previously  muffled  voice, — an  amendment  which,  however,  was  not  of 
long  duration.  I  purpose  trying  it  again  in  the  next  case  of  asthenic 
croup,  whether  idiopathic  or  secondary,  that  comes  under  my  notice. 

At  the  same  time  that  I  adopt  these  local  measures  I  employ  the 
tartar  emetic  in  the  same  manner  as  in  cases  of  simple  cynanche  tra- 
chealis,  except  that  it  is  not  always  desirable  to  give  it  in  such  fre- 
quently repeated  doses  as  in  the  other  more  active  malady.  If  relief 
be  not  speedily  obtained,  a  mustard  poultice  or  a  blister  should  be 
applied  to  the  throat.  In  any  case,  however,  where  the  vital  depression 
is  very  considerable,  the  mustard  poultice  only  should  be  employed, 
since,  under  such  circumstances,  a  vesicated  surface  in  the  child  often 
does  not  heal  favourably.  The  slower  course  which  these  cases  often 
run  affords  more  time  for  the  action  of  calomel  than  we  generally  have 
in  pure  cynanche  trachealis;  and  unless  the  presence  of  diarrhoea 
contraindicate  its  employment,  the  remedy  is  one  not  to  be  omitted. 
It  should  be  given  in  doses  of  one  grain  every  hour  to  a  child  of  three 
or  four  years  old,  combined  with  a  quarter  of  a  grain  of  ipecacuanha ; 
— but  if  the  symptoms  be  at  all  urgent,  the  emetic  should  be  repeated 
every  four  or  six  hours,  to  detach  any  false  membrane  that  may  have 
been  deposited  on  the  fauces ;  and  cauterization  should  be  practised 
again,  to  prevent  their  renewal.  As  improvement  advances  these 
remedies  may  be  repeated  at  longer  intervals,  while  expectoration  may 
be  promoted  by  the  employment  of  the  decoction  of  senega,  with  squills 
and  ammonia,  as  has  been  already  recommended.  Care  must  be  taken 
throughout  not  to  depress  the  child  too  much  by  over-active  treatment ; 
nourishment  must  be  given  from  an  early  period,  and  even  before  it  is 
safe  to  discontinue  the  cauterization  of  the  throat  and  the  occasional 
employment  of  emetics,  the  extract  of  bark  in  combination  with  its 
tincture,  or  some  other  form  of  direct  tonic,  may  be  needed. 

When  consequent  on  measles,  the  same  general  plan  of  treatment  must 
be  adopted,  though  with  far  slenderer  prospects  of  cure.  The  cauterization 
of  the  throat  is  in  such  cases  especially  necessary;  and  the  ulcerated 
condition  of  the  mouth  is  often  much  benefitted  by  the  frequent  applicaion 
to  it  of  a  solution  of  two  scruples  of  borax  in  an  ounce  of  water.  The 
tendency  to  diarrhoea  often  prevents  the  employment  of  calomel ;  while, 
owing  to  the  weakened  state  of  the  system,  we  cannot  always  venture  on 
the  use  of  antimony.     In  such  a  case,  we  may  still  have  recourse  to 


LARYNGITIS   STRIDULA.  237 

mercurial  inunction  ;  and  while  the  local  cauterization  is  most  seduously 
attended  to,  emetics  of  ipecacuanha  may  be  given  two  or  three  times  a 
day,  or  the  sulphate  of  copper  may  be  substituted  for  it  if  it  cause 
purging  or  fail  to  vomit.  Here,  however,  more  than  in  the  idiopathic 
form  of  the  affection,  we  find  in  many  instances  a  most  urgent  necessity 
for  supporting  the  child's  strength,  even  from  the  very  first.  The  occur- 
rence of  pneumonia  is  the  accident  most  to  be  dreaded  in  the  progress 
of  the  case,  and  may  require  a  modification  of  the  treatment,  though  in 
its  management,  the  asthenic  character  of  the  affection  must  always  be 
borne  in  mind.  Recovery  is  generally  very  slow,  even  in  cases  that 
terminate  favourably ;  and  it  often  happens  that,  after  all  alarming 
symptoms  have  been  removed,  the  voice  is  long  in  regaining  its 
proper  character. 

The  peculiar  sound  that  characterises  the  cough  of  the  croup,  the  stridor 
of  the  respiration,  and  the  urgent  dyspnoea,  which  attend  the  progress  of 
the  disease,  result,  as  I  scarcely  need  remind  you,  almost  entirely  from 
the  spasmodic  action  of  the  muscles  of  the  larynx,  and  not  from  the 
mechanical  obstacle  which  the  presence  of  false  membrane  offers  to  the 
free  admission  or  exit  of  air.  We  have  seen  that  these  symptoms  are, 
on  the  whole,  less  marked  in  cases  where  the  croup  appears  as  a  secondary 
affection,  and  the  larynx  becomes  involved  by  the  extension  to  it  of 
disease  beginning  in  the  throat,  than  in  those  where  the  air-passages 
themselves  are  primarily  affected.  Still,  they  vary  much,  both  in  the 
period  of  their  occurrence  and  the  degree  of  their  severity,  even  in  those 
cases  that  most  resemble  each  other ;  and  they  bear  no  certain  relation 
to  the  intensity  of  the  inflammation  anymore  than  to  the  amount  of  the 
deposit  of  false  membrane.  The  diversities  in  this  respect  depend  on 
constitutional  peculiarity  rather  than  on  any  essential  difference  in  the 
nature  of  the  disease. 

This  view,  indeed,  is  not  taken  by  all  writers,  but  some  observers  of 
deservedly  high  repute,  such,  for  instance,  as  M.  Guersent,1  have  con- 
ceived that  there  are  differences  sufficient  to  warrant  our  placing  in  a 
separate  category  those  cases  of  croup  which  are  marked  by  the  predo- 
minance of  spasmodic  symptoms.  They  have  proposed  to  designate  this 
form  of  the  disease  by  the  name  of  laryngitis  stridula,  to  distinguish  it 
from  ordinary  croup,  the  laryngitis  pseudomembranacea.  It  was 
doubtless  the  observation  of  some  cases  of  this  kind,  that  led  Dr.  Millar,2 
more  than  eighty  years  ago,  to  describe,  under  the  name  of  acute 
asthma,  a  disease  resembling  croup  in  many  respects,  but  presenting  a 
mixture  of  spasmodic  and  inflammatory  symptoms ;  the  former  predo- 
minating at  the  commencement  of  the  disease,  the  latter  towards  its 
close.  Dr.  Millar  appears,  indeed,  in  some  measure,  to  have  confounded 
two  very  different  affections, — the  true  spasmodic  croup,  or  laryngismus 
stridulus,  with  the  inflammatory  croup,  or  cynanche  trachealis,  under  the 
idea  that  they  constituted  the  two  stages  of  one  disease.  But  neverthe- 
less, cases  are  sometimes  observed  that  bear  a  very  close  resemblance 
to  Millar's  description  ;  though  no  advantage  seems  to  me  likely  to  arise 

1  In  the  article  Croup,  in  vol.  ix.  of  the  2d  edition  of  the  Dictionnaire  de  Medecine, 
&c      Paris,  1835. 

2  Observations  on  the  Asthma  and  on  the  Hooping-Cough,  8vo.     London,  1709. 


238      LARYNGITIS   STRIDULA — CASE  ILLUSTRATIVE   OF   ITS   SYMPTOMS. 

from  constituting  a  new  species  of  croup  out  of  a  modification  in  its 
symptoms  produced  by  the  idiosyncrasy  of  the  patient. 

In  some  children  there  is  a  greater  tendency  to  spasmodic  affections 
than  in  others  :  in  such  the  laryngeal  nerves  will  take  the  alarm  at  the 
very  outset  of  the  disease,  and  the  paroxysms  of  dyspnoea  will  conse- 
quently commence  at  an  early  stage,  and  will  soon  attain  great  intensity, 
but  may  become  masked  by  the  permanent  distress  of  breathing  to 
which  the  disease  in  its  progress  gives  rise.  In  other  instances,  the 
symptoms  of  inflammatory  disease,  and  those  of  spasmodic  disturbance, 
may  be  so  commingled,  or  may  so  alternate  with  each  other,  as  to  render 
it  hard  to  tell  from  which  the  child  suffers  most.  This  was  the  case 
with  a  little  boy  ten  months  old,  who  some  years  since  came  under  my 
care,  suffering  from  what  seemed  at  first  to  be  ordinary  inflammatory 
croup.  The  symptoms,  though  not  very  urgent,  were  plainly  marked, 
and  the  active  employment  of  antimony  soon  dissipated  them.  During 
the  whole  course  of  the  disease,  however,  the  child,  who  seemed  highly 
nervous  and  excitable,  suffered  from  fits  of  dyspnoea  far  more  severe 
than  could  have  been  anticipated  from  the  general  mildness  of  the 
attack,  or  than  would  have  been  supposed  to  exist  by  any  one  who  had 
seen  the  child,  only  in  the  intervals  of  the  paroxysms.  The  cough  and 
respiration  had  for  forty-eight  hours  entirely  lost'all  croupy  character,  and 
nothing  but  catarrh  seemed  left  behind,  when  the  child  was  suddenly 
seized  with  extreme  difficulty  of  breathing,  attended  with  slight  croupy 
noise,  and  lay  stiff  in  his  nurse's  arms  with  his  thumbs  drawn  into  the 
palms  of  his  hands,  and  his  great  toe  separated  from  the  others.  Four- 
and-twenty  hours  had  elapsed  from  the  supervention  of  these  new  symp- 
toms before  I  was  able  to  visit  the  child.  He  was  then  extremely 
restless  :  his  face  was  flushed,  his  thumbs  were  drawn  into  the  palms  of  his 
hands,  and  his  feet  were  forcibly  extended ;  his  breathing  was  laboured, 
and  attended  with  a  hoarse  croupy  sound,  which  became  still  more 
distinct  whenever  the  child  coughed.  The  bowels  had  not  acted  for  a 
couple  of  days,  but  an  hour  after  my  visit,  some  purgative  medicine,  of 
which  large  doses  had  been  given  during  the  previous  six  or  eight  hours 
began  to  act,  and  produced  three  very  copious  evacuations,  with  perfect 
relief  to  all  his  symptoms.  The  carpopedal  contractions  disappeared, 
the  respiration  became  easy,  and  the  face  ceased  to  be  flushed  or  anxious. 
The  child  slept  well  through  the  night,  was  cheerful  on  the  following 
day,  and  slight  hoarseness  attending  his  occasional  cough  was  the  only 
remaining  symptom.  In  a  day  or  two  that  also  disappeared,  and  the 
child  perfectly  recovered. 

The  influence  of  that  spasmodic  element  which  enters  so  largely  into 
the  production  of  the  symptoms  of  cynanche  trachealis,  is  seen  in  many 
cases  in  the  long  persistence  of  a  croupy  sound  with  the  cough,  and  in 
its  subsequent  recurrence,  when  a  patient  who  has  once  had  croup 
catches  cold.  In  these  cases  the  nerves  have  doubtless  not  thoroughly 
recovered  from  the  effects  of  the  previous  inflammation. 

The  spasmodic  character  of  many  of  the  symptoms  of  croup  will 
become  still  more  evident  when  we  observe,  as  we  shall  do  in  the  next 
lecture,  the  resemblance  which  they  bear  to  those  phenomena  that 
attend  some  of  the  more  purely  nervous  affections  of  the  respiratory 
organs. 


SPASM   OF   THE   GLOTTIS.  239 

Even  before  closing  this  lecture,  one  or  two  illustrations  may  be 
adduced  of  spasmodic  affection  of  the  larynx  in  connection  with  disease 
seated  elsewhere. 

MM.  Rilliet  and  Barthez  have  described  a  spasmodic  cough  that 
returns  in  paroxysms,  is  loud,  attended  with  an  imperfect  hoop,  and 
may. be  easily  taken  for  hooping-cough  by  the  inattentive  observer. 
It  is,  however,  a  symptom  of  bronchial  phthisis,  due  to  the  extension 
to  the  larynx  of  irritation  seated  in  a  distant  part  of  the  respiratory 
organs. 

Intestinal  irritation  is  a  frequent  cause  of  nervous  cough  in  childhood. 
It  is  sometimes  a  loud,  solitary,  ringing  cough-^-the  tussis  ovilla,  tussis 
ferina  of  medical  writers;  at  other  times  it  is  a  short  dry  cough, 
attended  with  no  particular  inconvenience,  but  teazing  from  its  fre- 
quency. Both  of  these  forms  appear  to  result  in  many  instances  from 
the  presence  of  worms,  and  speedily  cease  under  the  judicious  employ- 
ment of  purgative  medicines. 

Lastly,  I  may  once  more  remind  you  of  the  cough  which  is  occasion- 
ally heard  in  the  early  stage  of  inflammatory  affections  of  the  brain. 
It  is  a  very  short,  hoarse  cough,  which  sometimes  continues  for  a  few 
minutes  almost  incessantly,  then  ceases  for  a  time,  and  then,  after  a 
pause,  returns  again.  The  disturbance  of  the  brain  is  sympathized  in 
by  the  larynx,  and  the  depletion  which  relieves  the  former  organ, 
removes  the  irritation  of  the  latter. 


LECTURE    XXI. 

Spasm  of  the  Glottis. — Its  symptoms — description  of  the  carpopedal  contractions  that 
accompany  it — impairment  of  general  health — ways  in  which  it  proves  fatal — Mode 
of  its  production — its  various  exciting  causes,  dentition,  gastric  disorder,  local  irrita- 
tion from  enlarged  glands — supposed  to  depend  sometimes  on  enlargement  of  the 
thymus  gland — case  in  illustration. — Treatment — rules  for  diet  and  for  the  regulation 
of  the  bowels — caution  with  respect  to  lancing  the  gums — occasional  necessity  for  free 
depletion — case  in  illustration. — Suggestions  as  to  general  management,  and  the 
avoidance  of  circumstances  likely  to  produce  an  attack. 

We  have  often  had  occasion  to  notice  the  tendency  to  disorder  of 
the  nervous  system  that  characterizes  early  life,  and  have  just  now  seen 
to  how  great  a  degree  the  dangers  of  croup,  and  the  sufferings  that 
attend  it,  are  aggravated  by  the  sympathetic  disturbance  of  the  nervous 
system  with  which  it  is  almost  always  associated.  We  have  observed, 
too,  that  the  spasmodic  symptoms  of  this  disease  are  sometimes  quite 
out  of  proportion  to  the  severity  of  the  local  mischief;  and  that  in 
many  cases,  long  after  the  inflammation  has  subsided,  slight  stridor 
with  the  respiration,  and  a  degree  of  clangor  with  the  cough,  render  it 
probable  that  the  laryngeal  nerves  have  not  yet  regained  their 
accustomed  tone. 

Spasm  of  the  glottis,  however,  is  not  always  the  result  of  inflammation 
of  the  larynx,  and  a  mere  aggravation  of  danger  that  would  even  with- 


240  SPASM   OP   THE   GLOTTIS. 

out  it  be  considerable.  It  sometimes  constitutes  an  independent 
disease,  and  one  that  may  prove  suddenly  fatal,  even  though  the  larynx 
be  perfectly  healthy,  and  though  no  other  organ  present  changes 
adequate  to  account  for  the  patient's  death.  For  a  time  it  was 
confounded  with  cynanche  trachealis ;  but  the  points  of  difference 
between  the  two  affections  are  now  clearly  recognized,  and  the  terms 
spasm  of  the  glottis,  cerebral  croup,  spasmodic  croup,  by  which  it  is 
designated,  are  more  or  less  apt  expressions  of  its  connection  with 
disorder  of  the  nervous  system. 

Spasm  of  the  glottis, — which  term  I  select  as  the  simplest  among 
many  appellations  that  the  disorder  has  received, — usually  comes  on  by 
degrees,  and  it  is  but  seldom  that  its  early  symptoms  are  such  as  to  excite 
the  alarm  of  non-professional  persons.  It  does  not  often  occur  in 
perfectly  healthy  children  ;  but  an  infant  who  is  attacked  by  it  has  usually 
been  observed  to  be  drooping  for  some  time  previously,  to  have  lost  its 
appetite,  to  have  become  fretful  by  day  and  restless  at  night,  and  to 
present  many  of  those  ill-defined  ailments  which  are  popularly  ascribed 
to  teething.  At  length,  after  these  symptoms  have  continued  for  a 
few  days  or  weeks,  a  slight  crowing  sound  is  occasionally  heard  with 
the  child's  respiration.  The  sound  is  something  between  the  hoop  of 
hooping-cough  and  the  stridor  of  true  croup  ;  it  must  be  heard  to  be 
known,  but  when  once  heard  will  easily  be  recognized.  Usually  it  is  first 
noticed  on  the  child  awaking  out  of  sleep,  but  sometimes  it  is  perceived 
during  a  fit  of  crying,  or  comes  on  while  the  infant  is  sucking.  Now 
and  then  the  first  crow  is  very  loud,  and,  by  its  resemblance  to  the 
sound  of  croup,  at  once  alarms  the  family :  but  this  is  not  generally  the 
case ;  and  its  loudness  increases  in  proportion  as  its  return  becomes 
more  frequent.  The  spasm  may  have  been  excited  by  some  temporary 
cause,  and  the  sound  which  is  its  token  may  in  that  case  not  be  heard 
again  ;  but  generally  it  returns  after  the  lapse  of  a  few  hours,  or  of  a 
day  or  two.  It  will  soon  be  found,  as  its  return  becomes  more  frequent, 
that  certain  conditions  favour  its  occurrence ;  that  the  child  wakes 
suddenly  from  sleep  with  an  attack  of  it,  that  excitement  induces  it,  or 
deglutition,  or  the  effort  of  sucking  ;  so  that  the  child  will  suddenly 
drop  the  nipple,  make  a  croupy  sound  with  its  breathing,  and  then 
return  to  the  breast  again.  Throughout  the  whole  course  of  the  affection 
its  attacks  will  be  found  to  be  more  frequent  by  night  than  by  day  ; 
and  to  occur  mostly  either  soon  after  the  child  has  lain  down  to  sleep, 
or  towards  midnight,  when  the  first  sound  sleep  is  drawing  to  a  close. 

At  first  the  child  seems,  during  the  intervals  of  the  attack  in  as 
good  health  as  before, — except,  perhaps,  that  it  is  rather  more  pettish 
and  wilful;  but  it  is  not  long  before  graver  symptoms  than  the 
occasional  occurrence  of  an  unusual  sound  with  inspiration  excite 
attention,  and  give  rise  to  alarm.  Fits  of  difficult  breathing  occasionally 
come  on,  in  which  the  child  throws  its  head  back,  while  its  face  and 
lips  become  livid,  or  an  ashy  paleness  surrounds  the  mouth,  slight 
convulsive  movements  pass  over  the  muscles  of  the  face  ;  the  chest 
is  motionless,  and  suffocation  seems  impending.  But  in  a  few 
seconds  the  spasm  yields,  expiration  is  effected,  and  a  long  kud 
crowing  inspiration  succeeds,  or  the  child  begins  to  cry. 


SPASM   OF   THE   GLOTTIS.  241 

Breathing  now  goes  on  naturally ;  the  crowing  is  not  repeated,  or  the 
crying  ceases  ;  a  look  of  apprehension  dwells  for  a  moment  on  the 
infant's  features,  but  then  passes  away  ;  it  turns  once  more  to  its 
playthings,  or  begins  sucking  again  as  if  nothing  were  the  matter.  A  few 
hours,  or  even  a  few  days,  may  pass  before  this  alarming  occurrence 
is  again  observed  ;  but  it  does  recur,  and  another  symptom  of  the 
disturbance  of  the  nervous  system  is  soon  superadded,  if  it  have  not, 
as  is  sometimes  the  case,  existed  from  the  very  beginning.  This 
consists  in  a  peculiar  contraction  of  the  hands  and  feet ;  a  state  which 
is  likewise  not  infrequently  observed  during  infancy,  without  any 
spasmodic  affection  of  the  respiratory  organs.  It  differs  much  in 
degree  :  sometimes  the  thumb  is  drawn  into  the  palm  by  the  action 
of  its  adductor  muscles,  while  the  fingers  are  unaffected;  at  other 
times  the  fingers  are  closed  more  or  less  firmly,  and  the  thumb  is 
shut  into  the  palm  ;  or,  coupled  with  this,  the  hand  itself  is  forcibly 
flexed  on  the  wrist.  In  the  slightest  degree  of  affection  of  the  foot 
the  great  toe  is  drawn  a  little  away  from  the  other  toes ;  in  severer 
degrees  of  the  affection  this  abduction  of  the  great  toe  is  very  consider- 
able, and  the  whole  foot  is  forcibly  bent  upon  the  ankle,  and  its  sole 
directed  a  little  inwards.  Affection  of  the  hand  generally  precedes  the 
affection  of  the  foot,  and  may  even  exist  without  it ;  but  I  have  never 
seen  spasmodic  contraction  of  the  feet  when  the  hands  were  unaffected. 
At  first  this  state  is  temporary,  but  it  does  not  come  on  and  cease 
simultaneously  with  the  attacks  of  crowing  inspiration,  though  gene- 
rally much  aggravated  during  its  paroxysms.  Sometimes  a  child  in 
whom  the  crowing  inspiration  has  been  heard,  will  awake  in  the 
morning  with  the  hands  and  feet  firmly  flexed,  although  he  may  not 
have  had  any  attack  of  difficult  breathing-  during  the  night.  At 
other  times,  though  but  seldom,  this  state  will  subside  during  sleep  ; 
while  very  often  it  is  impossible  to  assign  any  reason  for  its  cessation 
or  return.  The  hands  may  often  be  unflexed  by  bending  the  fingers, 
but  they  will  resume  their  former  position  on  the  withdrawal  of  the 
force ;  and  such  attempts  are  painful  to  the  child.  When  the  contrac- 
tion is  but  slight,  children  still  use  their  hands ;  but  when  considerable 
they  cannot  employ  them,  and  they  sometimes  cry,  as  if  the  contrac- 
tion of  the  muscles  were  attended  with  pain.  Coupled  with  these 
carpopedal  contractions,  the  back  of  the  hand  and  the  instep  are 
sometimes  swollen,  tense  and  livid;  and  occasionally  there  is  slight 
puffiness  about  the  face.  This  condition  is  sometimes  more  general, 
and  on  two  successive  years  the  same  child  was  brought  to  me,  in 
whom  these  attacks  of  crowing  inspiration  were  accompanied  with  a 
state  of  tense  anasarca  of  the  whole  body.1 

When  the  disease  has  reached  this  degree  of  intensity,  a  slight 
crowing  sound  often  attends  each  inspiration,  and  the  paroxysms  of 
difficult  breathing  are  much  more  severe ;  they  last  longer,  and 
sometimes  terminate  in  general  convulsions.  The  breathing  now  does 
not  return  at  once  to  its  natural  frequency,  but  continues  hurried  for 

1  This  case  presented  a  remarkable  similarity  to  one  described  by  Dr.  M.  Hall,  at 
p.  185  of  his  work  on  the  Diseases  and  Derangements  of  the  Nervous  System.  8vo. 
Lond.  1841. 

16 


242  ITS   SYMPTOMS. 

a  few  minutes  after  the  occurrence  of  each  fit  of  dyspnoea  ;  and  it  is 
sometimes  attended  with  a  little  wheezing,  from  the  accumulation  of 
mucus  in  the  trachea  and  larger  bronchi  during  the  paroxysm.  When 
this  wheezing  is  permanent,  I  do  not  apprehend  that  it  constitutes  any 
essential  part  of  the  disease,  but  regard  it  either  as  due  to  an  accidental 
complication  with  catarrh,  which  is  so  frequent  during  the  period  of 
dentition,  or  as  the  result  of  the  affection  being  associated  with  tubercle 
in  the  lungs  or  bronchial  glands.  The  slightest  cause  is  now  sufficient 
to  bring  on  an  attack  of  difficult  breathing ;  it  may  be  produced  by  a 
current  of  air,  by  a  sudden  change  of  temperature,  by  slight  pressure 
on  the  larynx,  by  the  act  of  deglutition,  or  by  momentary  excitement. 
The  state  of  sleep  seems  particularly  favourable  to  its  occurrence,  and  the 
short  fitful  dozes  are  interrupted  by  the  return  of  impending  suffocation. 

The  general  condition  of  the  child  varies  much  during  the  existence 
of  these  symptoms,  but  is  always  widely  removed  from  a  state  of  health. 
The  bowels  are  almost  invariably  disordered,  constipation  being  more 
frequent  than  diarrhoea.  The  mouth  is  sometimes  hot,  and  the  gums 
are  swollen, — the  child  evidently  suffering  from  the  process  of  teething; 
and  this  is  the  state  with  which  spasm  of  the  glottis  is  perhaps  most 
frequently  associated.  Sometimes  there  is  evident  congestion  of  the 
brain,  and  the  face  is  flushed,  the  head  hot,  and  the  pulse  frequent; 
but  these  flushes  of  the  face  are  usually  temporary,  and  the  skin  is 
generally  pallid.  When  the  affection  has  continued  for  some  weeks,  the 
countenance  often  assumes  a  haggard,  miserable  aspect :  and  though  it 
may  come  on  in  children  apparently  in  good  health,  I  have  never 
known  the  health  continue  good,  after  the  disease,  even  in  a  mild 
form,  has  lasted  for  any  time. 

Death  sometimes  takes  place  during  one  of  the  paroxysms  of 
dyspnoea,  the  child  being  suffocated  by  the  long  continuance  of  the 
spasm ;  or  at  other  times  the  often  repeated  difficulty  of  breathing 
induces  a  state  of  permanent  cerebral  congestion :  general  convulsions 
occur,  and  the  child  dies  convulsed  or  comatose,  serous  effusion  having 
taken  place  into  the  ventricles  of  the  brain.  Should  the  child  escape 
both  these  dangers,  and  should  no  tubercular  disease  of  the  lungs  or 
bronchial  glands  exist,  recovery  is  almost  sure  eventually  to  take  place; 
though  the  convalescence  is  often  very  protracted,  and  the  attack  is 
apt  to  return  under  the  influence  of  the  same  causes  as  originally 
excited  it. 

Now,  though  for  convenience  sake  I  have  spoken  of  this  spasm  of 
the  glottis  as  if  it  were  an  independent  disease,  yet  the  crowing 
inspiration,  and  all  the  other  phenomena  that  attend  it,  are  merely  a 
collection  of  symptoms  betokening  disturbance  of  the  nervous  system 
in  general,  and  of  the  respiratory  nerves  in  particular.  The  causes 
that  may.  produce  such  disturbance  are  very  various,  and  according  to 
them  must  our  treatment  be  diversified.  Many  writers  have  over- 
looked this  fact,  and  fixing  their  attention  on  some  one  cause,  have  given 
a  defective,  if  not  an  erroneous  explanation  of  the  nature  of  the  affec- 
tion. But  this  is  not  the  case  with  Dr.  Marshall  Hall,  whose  appli- 
cation of  the  discovery  of  the  reflex  function  of  some* of  the  spinal 
nerves,  receives  some  of  its  most  beautiful  illustrations  from  this  affection. 


SPASM   OF   THE   GLOTTIS.  "  243 


"It  is,"  says  this  distinguished  physiologist,1  "excitation  of  the  true 
spinal  or  excito-motory  system."     It  originates  in — 

I.  1.  The  trifacial,  in  teething. 

2.  The  pneumogastric,  in  over-  or  improperly-fed  infants. 

3.  The    spinal   nerves,    in    constipation,    intestinal    disorder,    or 
catharsis.     These  act  through  the  medium  of — 

II.  The  spinal  marrow,  and 

III.  1.  The  inferior  or  recurrent  laryngeal,  the  constrictor  of  the 
larynx. 

2.  The  intercostals  and  diaphragmatic,  the  motors  of  res- 
piration." 

If  we  now  bear  in  mind  this  theory  of  the  disorder,  the  various 
circumstances  under  ivhich  it  is  met  with  will  no  longer  be  to  us  a 
source  of  difficulty.  The  great  share  which  dental  irritation  has  in  its 
production  is  shewn  by  the  age  at  which  it  generally  occurs.  Of  30 
cases  of  which  I  have  preserved  some  record,  24  occurred  in  children 
between  the  age  of  six  months  and  two  years,  or  just  at  that  period 
when  the  process  of  dentition  is  proceeding  most  actively,  and  its 
attendant  diseases  are  most  rife.  I  apprehend,  however,  that  we 
should  err  if  we  attributed  this  affection,  or  any  of  the  other  convulsive 
disorders  that  occur  at  this  time,  entirely  to  the  mechanical  irritation 
of  the  teeth,  pressing  on,  and  cutting  through,  the  gums.  The  period 
of  teething,  like  that  of  puberty,  constitutes  one  of  the  great  epochs  of 
life:  it  is  a  time  when  general  changes  are  going  on  in  the  whole 
organism, — when,  the  animal  machine  being  in  a  state  of  increased 
activity,  its  parts  are  more  than  usually  apt  to  get  out  of  order.  New 
diseases  appear,  or  such  as  were  before  of  rare  occurrence  become 
frequent ;  catarrhal  affections  and  disorders  of  the  intestinal  mucous 
membrane  are  extremely  prevalent,  and  the  brain  grows  more  than 
ever  liable  to  congestion  of  its  vessels.  Under  these  circumstances, 
spasm  of  the  glottis  often  occurs  as  the  secondary  rather  than  the 
primary  result  of  dentition.  The  child  has  cut  some  of  its  teeth  with- 
out any  symptom  of  disorder  of  the  nervous  system  making  its  appear- 
ance; but  at  length  it  suffers  an  attack  of  diarrhoea,  or  the  bowels  are 
allowed  to  become  constipated,  or  signs  of  cerebral  congestion  shew 
themselves.  The  crowing  sound  now  becomes  audible  with  the  inspira- 
tion, and  it  is  not  long  before  the  whole  train  of  symptoms  make  their 
appearance  which  it  has  been  my  object  to  describe.  It  may  be  that 
the  gums  were  not  swollen,  nor  any  tooth  near  the  surface,  just  at  the 
moment  when  the  signs  of  disturbance  of  the  nervous  system  made 
their  appearance ;  but  their  connection  with  the  process  of  dentition 
is  not  the  less  undeniable.  In  many  instances,  too,  though  these 
symptoms  may  subside  as  the  health  improves,  yet  they  will  return 
when  the  child,  cuts  another  tooth,  and  this  even  without  a  recurrence 
of  that  impairment  of  the  general  health  which  attended  tnem  on  the 
former  occasion. 

The  various  sources  of  irritation  that  give  rise  to  this  affection, 
however,  are  not  limited  to  the  period  of  teething;  and  hence  it  may 
be  met  with  before  the  commencement  of  that  process,  as  well  as  after 

1  Lib.  cit.  p.  71. 


244  ITS   CAUSES.   AND   MODE   OF   Pr6dDCTION. 

its  termination.  I  have  seen  it  in  a  child  ten  weeks  old,  as  a  conse- 
quence of  improper  feeding ;  in  another,  aged  nineteen  months,  it 
followed  the  sudden  suppression  of  long  continued  diarrhoea ;  in  a  third 
aged  two  years  and  a  half,  it  appeared  to  depend  on  a  state  of  cere- 
bral congestion  which  succeeded  to  habitual  constipation  ;  in  a  fourth, 
nine  months  old,  it  supervened  in  the  course  of  chronic  hydrocephalus ; 
and  in  a  fifth  child,  who  died  when  two  months  old,  it  appeared  as  a 
transitory  symptom  during  a  series  of  convulsive  attacks,  for  which  no 
cause  could  be  assigned  during  life,  and  which  left  no  traces  of  disease 
that  could  be  detected  after  death. 

But  besides  those  cases  in  which  spasm  of  the  glottis  is  induced 
by  irritation  set  up  in  some  distant  part,  there  are  others  in  which  the 
exciting  cause  of  the  affection  is  situated  near  to  the  larynx.  The 
late  Dr.  Hugh  Ley  observed  several  instances  of  this  kind,  in  which 
the  attack  appeared  to  be  due  to  the  presence  of  enlarged  and 
tuberculous  cervical  and  bronchial  glands ;  and  similar  cases  have 
come  under  my  own  notice.  Dr.  Ley,  indeed,  based  upon  his  dissec- 
tions a  theory  of  the  disease  which  is  now  known  to  be  erroneous; 
but  it  will  not  excite  your  surprise  that  a  mass  of  bronchial  glands, 
compressing  and  flattening  the  pneumo-gastric  and  recurrent  nerves 
(as  you  see  represented  in  these  plates1),  should  in  many  instances 
excite  irritation  of  those  nerves,  and  give  rise  to  spasm  in  the  parts  to 
which  they  are  distributed. 

Symptoms  of  a  kind  closely  resembling  those  which  we  have  been 
studying,  are  now  and  then  observed  in  infants  in  connection  with  a 
hypertrophied  state  of  the  thymus  gland ;  and  the  affection  has,  in 
such  cases,  received  the  name  of  thymic  asthma. 

The  only  instance  of  the  kind  that  has  come  under  my  own  notice 
occurred  in  a  little  boy,  who  was  brought  to  me  at  the  age  of  six 
months,  suffering  from  symptoms  which  his  mother  said  had  existed, 
though  in  a  less  aggravated  degree,  almost  from  the  time  of  his  birth ; 
but  which  had  not  much  alarmed  her  until  they  were  followed  by  an 
attack  of  general  convulsions  a  day  or  two  before  I  saw  the  child. — 
These  symptoms  consisted  in  the  occasional  occurrence  of  great  diffi- 
culty in  breathing  attended  with  considerable  livor  of  the  surface, 
continuing  for  a  very  short  time  and  returning  every  two  or  three 
weeks  without  any  assignable  cause.  From  the  sixth  month  the 
child  seemed  very  liable  to  catch  cold,  and  had  frequent  cough  and 
wheezing ;  but  a  little  rhonchus  was  all  that  was  ever  perceptible  in 
the  lungs ;  and  febrile  symptoms  were  at  no  time  apparent.  The 
attacks  of  difficult  breathing  often  occurred  at  night,  the  child  waking 
from  sleep  with  them,  or  they  were  sometimes  produced  by  deglutition, 
which  process  always  seemed  to  be  attended  with  slight  difficulty 
whenever  fhe  child  attempted,  as  it  grew  older,  to  swallow  semi- solid 
substances.  It  was  remarkable  that  no  distinct  crowing  sound  ever 
attended  the  inspiration ;  but  that  the  child  having  turned  ex- 
tremely livid  during  the  paroxysm  of  dyspnoea,  gradually  recovered 
its  breath,  and  the  livor  and  anxiety  of  the  countenance  disappeared  by 

1  Ley  on  the  Laryngismus  Stridulus,  8vo.  Plates  1  and  2.     London,  183C. 


THYMIC   ASTHMA.-  245 

degrees.  Profuse  perspiration  about  the  head  generally  followed 
these  seizures ;  and  sometimes  the  child  would  pass  into  a  state  of 
general  convulsions,  in  which,  however,  it  did  not  struggle  much,  but 
continued  to  breathe  hurriedly  for  some  time  after  they  had  passed  off*. 
From  about  the  ninth  month,  slight  cough  was  almost  constantly 
present,  though  still  unattended  with  any  febrile  disturbance ;  the 
head  was  sometimes  very  hot,  and  the  difficulty  of  deglutition,  the 
dyspnoea,  and  the  convulsions,  increased  both  in  severity  and  in  the 
frequency  of  their  recurrence.  The  child  now  cut  the  two  lower 
incisors,  but  without  any  change  taking  place  in  his  general  condition. 
Two  or  three  weeks  before  his  death,  which  took  place  when  just  a 
twelvemonth  old,  he  had  an  attack  of  coryza,  with  abundant  puriform 
discharge,  which  by  its  hardening  blocked  up  the  nostrils,  and  caused 
a  good  deal  of  distress  in  breathing,  though  unattended  by  any  really 
grave  symptom.  He  was  recovering  from  this,  when  one  morning 
early  a  paroxysm  of  dyspnoea  came  on,  which  was  followed  by  a 
slight  fit  that  left  him  pale  and  exhausted.  About  two  hours  afterwards 
his  breathing  not  having  become  as  quiet  and  natural  as  before  the 
first  paroxysm,  another  attack  came  on,  in  which  he  died. 

On  examining  the  body  after  death,  the  lividity  of  all  the  depending 
parts  was  very  remarkable. 

The  pericranium  stripped  off  very  easily  from  the  bones  of  the 
skull,  which  were  exceedingly  vascular.  There  was  considerable 
vascularity  of  the  dura  mater,  the  sinuses  of  which,  and  the  cerebral 
veins  generally,  were  gorged  with  fluid  blood.  There  was  no  injection 
of  the  pia  mater ;  sections  of  the  brain  presented  a  rather  greater 
number  of  bloody  points  than  natural,  but  its  substance  was  firm,  and 
the  lateral  ventricles  contained  but  little  fluid. 

The  first  object  seen  on  opening  the  chest  was  the  thymus  gland, 
which  occupied  the  whole  of  the  anterior  mediastinum,  and  nearly 
concealed  the  heart.  Its  structure  was  apparently  natural ;  its  length 
was  3f  inches,  and  it  weighed  328J  grains. 

The  heart  was  extremely  large,  as  large  as  the  heart  of  a  child  of 
three  years  old.  Its  auricles  and  the  veins,  both  the  cavae  and  the 
pulmonary  veins,  were  full  of  fluid  blood.  The  organ  was  not  well 
contracted  ;  its  structure  was  perfectly  healthy,  and  the  foetal  openings 
were  closed. 

There  was  a  good  deal  of  thick  mucus  in  the  trachea  and  bronchi, 
but  they  were  perfectly  healthy :  and  the  rest  of  the  body  presented  no 
remarkable  appearance,  except  that  a  considerable  extent  of  both  lungs 
was  in  a  state  of  carnification. 

Now,  notwithstanding  some  points  of  difference  between  this  case 
and  those  in  which  spasm  of  the  glottis  has  been  induced  by  a  different 
cause,  yet  we  recognise  in  it  the  grand  symptoms  of  the  affection.  The 
enlargement  of  the  thymus  appears  to  have  induced  permanent  irrita- 
tion about  the  windpipe,  which  betrayed  itself  by  the  frequent  cough, 
and  the  constant  wheezing.  To  the  same  cause,  too,  must  be  referred 
the  difficult  deglutition,  while  the  convulsions  were  probably  much 
favoured  by  the  enlarged  gland  pressing  upon  the  superior  cava  and 


246  CASE   ILLUSTRATIVE   OF  ITS   SYMPTOMS. 

right  auricle,1  and  thus  impeding  the  return  of  blood  from  the  head  : 
nor  must  we  forget,  among  the  probable  causes  of  the  child's  sudden 
death,  the  remarkable  degree  of  cardiac  hypertrophy.  The  fatal  event, 
however,  might  possibly  not  have  occurred  but  for  the  attack  of  coryza, 
and  the  consequent  impairment  of  the  respiratory  function,  which 
naturally  tended  to  increase  the  congestion  of  the  brain. 

The  treatment  of  spasm  of  the  glottis  must  be  regulated  by  the 
nature  of  its  exciting  cause ;  and  this,  as  you  have  already  seen,  varies 
much  in  different  cases.  In  infants  before  the  period  of  dentition,  it  is 
usually  induced  by  over-feeding,  or  by  food  of  an  improper  kind.  Our 
inquiries,  therefore,  must  at  once  be  directed  to  ascertain  how  the 
infant  is  fed ;  and  supposing  it  to  be  still  suckled,  it  will  be  wise  to 
interdict  any  other  food  than  the  mother's  milk, — or,  at  most,  to  allow 
only  a  little  barley-water.  Spasm  of  the  glottis,  however,  occurs  much 
oftener  in  infants  who  are  brought  up  by  hand,  or  in  those  who  have 
been  weaned,  than  in  children  still  at  the  breast.  In  such  cases,  much 
pains  are  sometimes  necessary  in  order  to  ascertain  precisely  the  kind 
of  food  that  best  suits  the  infant.  Two  parts  of  milk  and  one  of 
barley-water,  sweetened  with  a  little  loaf  sugar;  or  equal  parts  of  milk 
and  of  a  solution  of  isinglass,  made  of  the  thickness  of  barley-water, 
generally  agfee  very  well ;  but  much  caution  must  be  used  in  the 
introduction  of  farinaceous  articles  into  the  child's  diet.  Asses'  milk, 
which  forms  the  nearest  approach  to  its  natural  food,  must  sometimes 
be  given  till  the  child  has  decidedly  improved;  while,  if  it  be  puny, 
and  do  not  appear  to  thrive,  and  the  crowing  inspiration  continue 
undiminished,  it  may  become  absolutely  necessary  to  restore  it  to 
the  breast. 

The  state  of  the  bowels  requires  no  less  attention  than  the  regulation 
of  the  diet.  The  tendency  to  constipation  must  be  combated  not  by 
drastic  purgatives,  but  by  mild  aperients.  Castor  oil  often  answers 
the  purpose  very  well,  but  sometimes  each  dose  of  it  nauseates  a  child 
for  several  hours,  and  then  it  is  not  desirable  to  employ  \t  if  a  daily 
aperient  should  be  needed.  Both  senna  and  manna  are  apt  to  gripe  ; 
and  if  they  be  found  on  trial  to  produce  this  effect,  their  use  must  not 
be  persevered  in.  Few  medicines  act  more  mildly  or  more  certainly 
in  children  than  aloes ;  and  the  bitter  of  the  compound  decoction  may 
be  much  concealed  by  extract  of  liquorice.  The  bulk  of  a  medicine, 
however,  often  opposes  a  great  difficulty  to  its  employment  in  infancy  ; 
and  if  that  be  the  case,  the  powder  may  be  substituted  for  the  decoction. 
If  slightly  moistened,  mixed  with  a  little  coarse  sugar,  and  placed  on 
the  tongue,  it  will  often  be  swallowed  very  readily.  The  habitual  use  of 
mercurials  to  overcome  the  constipation  is  not  desirable :  their  employ- 
ment is  better  limited  to  those  cases  in  which  the  bowels  are  not  only 
sluggish,  but  the  evacuations  unnatural  in  character. 

The  action  of  the  bowels  may  be  encouraged  by  rubbing  the  abdomen 
twice  a  day  with  a  liniment  composed  of  equal  parts  of  soap  liniment 
and  tincture  of  aloes ;  or  the  bowels  may  sometimes  be  induced  to  act 

1  Ha8se  suggests  in  his  (Specielle  pathologische  Anatomie,  p.  519,  Leip.  1841)  that 
this  circumstance  contributes  to  the  production  of  the  sudden  death  in  thymic  asthma, 
—a  supposition  which  the  case  recorded  above  certainly  tends  to  bear  out. 


TREATMENT  OF  SPASM  OF  THE  GLOTTIS.  247 

regularly  in  young  infants,  by  the  daily  employment  of  a  small  soap 
suppository.  Enemata,  consisting  either  of  warm  water,  or  gruel,  may 
also  be  given  for  the  same  purpose. 

Sedulous  attention  to  the  diet  and  the  state  of  the  bowels  will  some- 
times effect  a  cure ;  but  in  many  instances  tonics  may  be  employed 
with  advantage,  and  probably  none  with  such  decided  benefit  as  the 
preparations  of  iron.  Removal  to  the  pure  air,  however,  or  to  the  sea 
coast,  is  often  a  tonic  of  greater  power  in  these  cases  than  all  the  con- 
tents of  the  laboratory,  and  one  which  you  will  find  in  some  instances 
to  be  absolutely  indispensable  to  the  child's  cure. 

All  these  cares  are  not  less  needed  in  children  in  whom  the  process 
of  dentition  has  already  commenced.  In  them,  however,  the  irritation 
of  teething  is  often  the  exciting  cause  of  the  affection,  and  lancing  the 
gums  is  frequently  needed  in  addition  to  the  other  treatment.  The 
relief  thus  afforded  is  sometimes  very  striking ;  and  the  frequent 
repetition  of  the  process  may  be  necessary  to  diminish  the  swelling 
and  tension,  and  to  ease  the  pain  of  the  congested  gum.  It  is  not, 
however,  a  proceeding  to  be  adopted,  irrespective  of  all  ether  consid- 
erations, simply  because  the  child  had  begun  to  cut  his  teeth  when  the 
attack  of  spasm  of  the  glottis  came  on.  Dentition  does  not  go  on 
continuously  from  the  time  when  the  first  tooth  is  cut  until  the  com- 
pletion of  the  whole  set,  but  there  are  regular  pauses  in  the  process, 
during  which  its  advance  is  suspended  for  several  weeks  together. 
Thus  for  instance,  after  the  appearance  of  the  incisors,  there  is  a  pause 
of  several  weeks  or  months  before  the  first  molar  teeth  appear,  and 
then  there  is  another  cessation  in  the  process  before  the  child  begins 
to  cut  its  canine  teeth.  The  spasm  of  the  glottis,  therefore,  may  come 
on  during  one  of  these  pauses,  and  be  excited  by  some  cause  quite 
unconnected  with  dentition.  Lancing  the  gums,  too,  is  not  well  borne 
in  every  case,  even  when  it  may  have  disappeared  to  be  indicated; 
and  I  have  more  than  once  been  compelled  to  discontinue  it,  on  account 
of  the  pain  and  alarm  which  it  excited  bringing  on  a  violent  spasmodic 
seizure,  whenever  I  attempted  to  practise  it. 

In  some  instances  the  spasm  of  the  glottis  is  associated  with  manifest 
uneasiness  in  the  head.  It  has  been  suggested,  that  in  some  of  these 
cases  the  brain  is  kept  in  a  state  of  constant  irritation,  owing  to  the 
deficiently  ossified  skull  being  too  thin  to  defend  it  from  injury,  while 
at  the  same  time  it  affords  no  adequate  counter-pressure  to  check  the 
over-distension  of  the  cerebral  vessels.  I  have  seen  one  case  that 
seemed  to  lend  decided  support  to  this  opinion,  and  many  others  have 
come  under  my  notice,  in  which  the  recommendation  that  a  horse-hair 
cushion  should  be  made  for  the  head  to  rest  on,  having  a  hole  in  its 
centre,  so  as  to  relieve  the  occiput  from  all  pressure,  has  been  acted  on 
with  manifest  advantage.  The  supervention  of  attacks  of  spasm  of  the 
glottis,  in  a  case  of  well-marked  chronic  hydrocephalus,  would  call  for 
little  change  in  the  treatment,  though  it  must  evidently  add  much  to 
the  danger  of  the  patient. 

Symptoms  of  cerebral  congestion  are  sometimes  associated  with  this 
condition.     They  are  seldom  such  as  to  call  for  active  interference ; 


248      SPASM   OF   THE   GLOTTIS  ASSOCIATED   WITH   CEREBRAL   CONGESTION. 

but  the  tepid  bath  and  neutral  salines,  with  small  doses  of  hyoscyamus,1 
are  often  of  much  service  in  quieting  the  general  excitement  of  the 
circulation,  while  the  occasional  application  of  a  leech  to  the  head  may 
be  beneficial,  especially  if  general  convulsions  are  beginning  to  super- 
vene on  the  attacks  of  dyspnoea. 

It  is  possible  that  you  may  meet  with  a  case  in  which  active  depletion 
is  indicated,  and  you  must  not  allow  the  consciousness,  that,  as  a  general 
rule,  it  is  inappropriate,  to  prevent  you  from  having  recourse  to  it  in 
such  exceptional  instances  as  the  following.  In  this  case,  indeed,  it 
was  found  necessary  to  carry  depletion  beyond  that  point  which  is  in 
general  expedient  in  so  young  a  child. 

Some  years  since  I  saw  a  little  boy,  2J  years  old,  who  had  already 
suffered  from  several  attacks  of  spasm  of  the  glottis.  A  return  of  the 
affection  had  taken  place  about  seven  weeks  before,  though  not  attended 
by  any  very  alarming  symptoms  until  after  the  lapse  of  a  month,  when 
a  general  convulsive  seizure  occurred.  From  this  he  recovered,  and  he 
had  for  some  days  appeared  to  be  convalescent  from  the  spasmodic 
seizures,  when  his  bowels  became  disordered,  and  a  good  deal  purged, 
and  after  they  had  been  so  for  two  or  three  days  his  mother  noticed 
one  afternoon  that  his  thumbs  were  forcibly  drawn  into  the  palm  of  his 
hands.  With  the  exception  of  this  contraction  of  his  thumbs,  however, 
he  seemed  as  wrell  as  usual,  and  had  a  tolerably  good  night ;  but  imme- 
diately on  awaking  at  six  o'clock  on  the  following  morning  he  had  a 
paroxysm  of  stridulous  breathing,  in  which  he  crowed  so  loudly  as  to  be 
heard  over  the  wThole  house.  His  face  at  the  same  time  became  greatly 
flushed,  and  his  hands  and  feet  contracted,  as  they  were  when  I  visited 
him  three  hours  afterwards.  His  face  was  then  much  flushed,  his  head 
hot,  his  pupils  rather  dilated,  his  pulse  full  and  bounding ;  his  thumbs 
were  drawn  across  the  palm ;  the  fingers  were  not  closed,  but  the  hands 
were  forcibly  flexed  on  the  wrrist ;  the  great  toe  was  drawn  far  apart 
from  the  other  toes,  which  were  flexed,  and  the  whole  foot  was  stiffly 
bent  on  the  ankle.  The  child  was  then  breathing  quietly,  and  seemed 
drowsy ;  but  he  screamed  out  the  moment  he  was  touched,  as  if  the 
least  disturbance  of  his  limbs  gave  him  pain. 

Eight  leeches  were  applied  to  his  temples,  and  drew  much  blood,  but 
without  producing  any  amelioration  of  his  condition.  A  croupy  sound 
continued  to  attend  his  respiration,  and  he  had  a  fit  of  urgent  dyspnoea, 
with  loud  stridulous  breathing,  between  my  first  visit  at  9  in  the 
morning,  and  my  second  at  5  in  the  evening.  I  now  bled  him  from  the 
arm  to  3vj.  which  subdued  the  fulness  of  the  pulse,  blanched  his  lips, 
and  diminished  the  flush  of  his  face,  though  it  did  not  cause  actual 
fainting.  I  ordered  cold  to  be  applied  to  the  head,  and  saw  him  again 
at  1\  P.M.,  when  I  found  that  he  had  been  lying  quiet  ever  since  I  left  him, 
and  had  had  some  tranquil  sleep,  without  any  crowing  sound  attending 
the  breathing.  His  pulse  was  less  full,  the  flush  of  his  face  diminished, 
the  heat  of  the  head  was  gone,  and  the  contraction  of  the  hands  and 
feet  were  both  less,  and  less  firm. 

A  powder  with  gr.  j.  of  calomel  and  gr.  viij.  of  rhubarb,  which  had 

1  See  Formula  No.  2.  p.  43. 


NECESSITY   FOR  DEPLETION — CURE.  249 

been  given  in  the  morning,  and  had  produced  one  evacuation,  was  now- 
repeated. 

The  child  had  some  sleep  in  the  night,  and  no  access  of  dyspnoea 
returned,  nor  did  the  croupy  sound  again  accompany  the  inspiration. 
In  the  course  of  the  day  the  spasmodic  contractions  of  the  hands  and 
feet  greatly  diminished,  and  the  child  became  cheerful.  In  five  days 
from  this  formidable  attack  he  was  quite  well,  and  continued  so  for  a 
year,  when  a  slight  return  of  spasm  of  the  glottis  took  place,  in  the 
course  of  a  severe  impetiginous  eruption  on  the  scalp. 

Before  concluding  this  lecture,  I  will  suggest  a  few  cautions,  appli- 
cable alike  to  all  cases  of  spasm  of  the  glottis.  Sudden  excitement,  and 
especially  a  fit  of  crying,  are  likely  to  bring  on  the  attack,  and  since 
there  is  a  possibility  of  any  one  of  these  attacks  proving  fatal,  the 
greatest  care  must  be  taken  in  the  management  of  the  child  to  avoid 
all  unnecessary  occasions  of  annoyance  or  distress. 

Although  the  benefit  that  accrues  from  fresh  air,  or  from  a  change 
of  air,  is  often  very  great,  yet  it  is  very  important  that  the  child  should 
not  be  exposed  to  the  cold  or  wind,  for  I  have  seen  such  exposure  fol- 
lowed by  a  severe  attack  of  dyspnoea,  or  by  the  occurrence  of  general 
convulsions.  The  hazard  of  such  an  occurrence  is  greater  in  propor- 
tion to  the  severity  and  long  continuance  of  the  affection ;  and,  in  such 
cases,  the  excitability  of  the  spinal  cord,  and  the  irritability  of  the  sur- 
face, seem  sometimes  to  become  as  great  as  they  may  be  observed  to 
be  in  frogs  when  narcotized,  whom  you  may  then  throw  into  convul- 
sions by  merely  shaking  the  table  on  which  they  are  placed.  It  is 
possible  that  this  condition  in  the  infant  may  be  due  to  a  cause  not 
unlike  that  which  produces  it  in  the  lower  animal.  In  the  latter,  it  is 
manifestly  due  to  the  influence  on  the  nervous  system,  of  blood  impreg- 
nated with  opium ;  in  the  former,  a  similar  influence  may  be  exerted 
by  blood,  the  proper  depuration  of  which  has  been  prevented  by  the 
frequent  recurrence  of  spasm  of  the  glottis. 

There  is  also  another  reason  for  caution  in  exposing  the  child  to  cold 
or  wind,  namely,  that  the  occurrence  of  catarrh  is  almost  sure  to  be 
followed  by  an  aggravation  of  the  spasmodic  affection.  On  more  than 
one  occasion  I  have  seen  the  supervention  of  catarrh  convert  a  very 
mild  into  a  very  serious  attack;  and  once,  the  exacerbation  of  the 
symptoms  thus  produced  was  the  cause  of  the  infant's  death. 

The  parents  should  in  every  instance  be  made  fully  aware  of  the 
uncertainty  that  attends  this  affection, — of  the  possibility  of  death 
taking  place  very  suddenly  and  unexpectedly. 

In  the  paroxysm  itself  but  little  can  be  done.  Cold  water  may  be 
dashed  on  the  face,  and  the  fauces  may  be  irritated,  or  the  finger  passed 
down  into  the  pharynx,  so  as  to  bring  on  if  possible  the  effort  to  vomit, 
while  at  the  same  time  the  legs  and  lower  part  of  the  body  may  be 
placed  in  a  hot  bath. 

Lastly,  1  will  observe  that  a  plan  of  treatment  different  from  that 
just  laid  down  has  been  suggested  as  applicable  to  those  cases  in  which 
spasm  of  the  glottis  is  excited  by  hypertrophy  of  the  thymus  gland.1 

1  Dr.  J.  H.  Kopp,  Denkwiirdigkeiten  in  der  arztlichen  Praxis,  8vo.  vol.  i.  pp.  77-107. 
Frankfort,  1830. 


250        GENERAL   MANAGEMENT   OF   CASES   OF   SPASM   OF   THE   GLOTTIS. 

A  spare  diet,  the  continued  administration  of  small  doses  of  calomel, 
and  the  keeping  a  small  blister  open  on  the  sternum  for  months  toge- 
ther, have  been  advised  as  means  of  promoting  the  absorption  of  the 
gland.  I  cannot  speak  of  the  merits  of  this  practice  from  experience, 
but  it  is  liable  to  two  great  objections ;  since,  not  only  have  we  no 
means  of  distinguishing  with  certainty  between  cases  of  spasm  of  the 
glottis  that  depend  on  hypertrophy  of  the  thymus,  and  those  much  more 
numerous  instances  of  the  affection  in  which  the  gland  retains  its 
natural  size,  but  also,  the  large  thymus  is  probably,  as  suggested  by 
Dr.  Schopf-Merei,1  in  the  great  majority  of  cases,  a  mere  persistence 
of  a  foetal  condition  connected  with  the  generally  backward  development 
of  the  child,  rather  than  actual  overgrowth  of  the  organ. 


LECTURE    XXII. 

Hooping-Cough — Course  of  the  disease  in  its  simplest  form — subject  to  great  variations 
in  its  mode  of  onset  and  degree  of  severity. — Signification  of  the  hoop. — Course  of 
the  disease  when  declining — Its  danger  depends  on  its  complications — Complication 
with  bronchitis — at  its  outset,  or  when  it  has  continued  for  some  time — Complication 
with  disorder  of  the  nervous  system — sometimes  exists  from  the  first  and  causes  death 
even  before  characters  of  disease  are  fully  developed — but  may  come  on  at  any 
period — various  forms  assumed  by  disorder  of  nervous  system — great  danger  when 
paroxysms  of  cough  terminate  in  convulsions — caution  as  to  nervous  character  of 
dyspnoea  in  many  cases,  and  as  to  danger  of  overtreating  it. — True  hydrocephalus 
rare  as  a  complication. 

We  pass  to-day  to  the  study  of  one  of  the  most  common  disorders 
of  childhood.  Pew  persons  attain  to  adult  age  without  having  experi- 
enced an  attack  of  hooping-cough,  and  still  fewer  of  those  who  escape 
it  when  children  suffer  from  it  in  after  life. 

Hooping-cough,  then,  claims  our  notice  as  being  essentially  a  disease 
of  early  life ;  but  as  it  is  one  which  almost  every  old  woman  professes 
to  cure,  we  might  fairly  expect  not  to  be  detained  long  with  its  study. 
We  find,  however,  that  in  this  metropolis  it  ranks  fourth  among  the 
causes  of  death  under  five  years  of  age  ;  inflammation  of  the  lungs, 
convulsions,  and  hydrocephalus,  being  the  only  more  fatal  ailments. — 
A  cursory  inquiry  will  not  suffice  to  make  us  thoroughly  acquainted 
with  all  points  of  importance  in  the  history  of  a  disease  that  has  so 
many  victims. 

The  aifection  in  its  simplest  form  consists  of  a  cough  of  spasmodic 
character,  that  usually  succeeds  to  catarrhal  symptoms,  and  having 
recurred  at  intervals  for  a  few  weeks,  ceases  without  having  occasioned 
any  serious  disturbance  of  the  general  health,  or  required  any  active 
medical  treatment.  In  its  graver  forms  it  is  one  of  the  most  fearful 
diseases  that  we  ever  have  to  encounter,  often  keeping  the  life  of  the 
patient  for  days  or  weeks  together  in  almost  constant  jeopardy,  liable 

1  In  his  very  interesting  essay  on  Spasms  and  Convulsions  of  Children,  in  the  Monthly 
Journal  of  Medical  Science,  for  1850. 


SYMPTOMS   OF    HOOPING-COUGH.  251 

to  be  exaggerated  by  the  most  trivial  cause,  or  rendered  fatal  by  the 
slightest  error  in  treatment ;  while  the  highest  effort  of  our  art  is 
limited  to  mitigatir/g  the  severity  and  warding  off  the  urgent  danger 
of  symptoms  which  we  are  unable  wholly  to  subdue,  and  which  we 
must  trust  to  time  and  nature  thoroughly  to  cure. 

Such  great  differences  in  the  course  of  the  disease  in  different  cases 
have  given  rise  to  many  ingenious  theories  as  to  its  nature  and  seat, 
framed  with  the  view  of  explaining  that  which  cannot  but  strike  all 
observers  as  so  enigmatical  in  its  character.  None  of  these  specu- 
lations, however,  have  led  to  any  useful  practical  result,  and  we  shall 
be  better  employed  than  in  their  study,  if  we  confine  ourselves  to  the 
simple  observation  of the  phenomena  of  the  disease.  In  doing  this,  we 
will  begin  with  those  cases  in  which  it  is  most  simple  and  least  perilous, 
and  will  then  examine  in  succession  the  different  modes  in  which  its 
course  becomes  complicated  and  dangerous. 

An  attack  of  hooping-cough  usually  begins  with  catarrh,  and 
presents  at  first  little  or  nothing  to  distinguish  it  from  a  common  cold, 
except  that  sometimes  the  cough  is  attended  almost  from  the  outset 
with  a  peculiar  ringing  sound.  By  degrees  the  catarrhal  symptoms 
abate,  and  the  slight  disturbance  of  the  child's  health  altogether 
ceases,  but  nevertheless  the  cough  continues;  it  grows  louder,  and 
lasts  longer  than  before,  and  assumes  something  of  a  suffocative 
character,  in  all  of  which  respects  a  tendency  to  exacerbation  towards 
night  becomes  early  apparent.  As  the  cough  grows  severer,  its  pecu- 
liarities become  more  and  more  manifest ;  during  each  paroxysm  the 
child  turns  red  in  the  face,  and  its  whole  frame  is  shaken  with  the 
violence  of  the  cough.  Each  fit  of  coughing  is  now  made  up  of  a 
number  of  short,  hurried  expirations,  so  forcible,  and  succeeding  each 
other  with  such  rapidity,  that  the  lungs  are  emptied,  to  a  great  degree, 
of  air,  and  the  child  is  brought  by  their  continuance  into  a  condition 
of  impending  suffocation.  At  length,  the  child  draws  breath  with  a 
long,  loud  sonorous  inspiration, — the  hoop  from  which  the  disease 
derives  its  name, — and  the  attack  sometimes  terminates.  More  often, 
however,  the  hoop  is  followed  by  but  a  momentary  pause,  and  the 
hurried  expiratory  efforts  begin  again,  and  are  again  arrested  by  the 
loud  inspiration  ;  perhaps  only  to  recommence,  until,  after  the  abundant 
expectoration  of  glairy  mucus,  or  retchitig,  or  actual  vomiting,  free 
inspiration  takes  place,  and  quiet  breathing  by  degrees  returns.  If 
you  listen  to  the  chest  during  a  fit  of  hooping-cough,  you  will  hear  no 
sound  whatever  in  the  lungs ;  but  when  the  hoop  occurs,  you  will  once 
more  perceive  air  entering,  though  not  penetrating  into  the  minuter 
bronchi.  It  is  not  till  the  fit  is  over,  and  respiration  once  more  goes 
on  quietly,  that  the  air  reaches  the  pulmonary  cells  again ;  but  then 
you  will  hear  vesicular  murmur  as  clear  as  if  nothing  ailed  the  child 
or  at  most  interrupted  only  by  a  little  rhonchus,  or  slight  mucous 
rale.  If  the  cough  be  severe,  quiet  breathing  does  not  return,  nor  the 
vesicular  breathing  become  audible,  till  some  time  after  the  paroxysm 
is  over  ;  and  occasionally,  short  and  laborious  breathing  ushers  in  each 
fit  of  coughing.  The  child  then  seems  to  have  a  presentiment  of  the 
coming  seizure ;  its  face  grows  anxious,  it  looks  up  at  its  mother,  and 


252  SYMPTOMS   OF   HOOPING-COUGH. 

clings  more  closely  to  her,  or  if  old  enough  to  run  about,  you  may 
observe  it  even  before  its  breathing  has  become  manifestly  affected, 
throw  down  its  playthings,  and  hasten  to  seize  hold  of  a  chair,  or  of 
some  article  of  furniture,  for  support  during  the  approaching  fit  of 
coughing. 

If  the  case  be  uncomplicated,  even  though  the  attack  be  severe,  the 
child's  health  continues  good,  and  little  or  nothing  ails  it  during  the 
intervals  of  the  cough.  Its  appetite  is  not  impaired,  but  after  throwing 
up  the  contents  of  the  stomach  in  a  fit  of  coughing,  it  asks  for  food 
almost  immediately.  It  sleeps  soundly,  except  when  roused  by  the 
cough ;  the  bowels  act  regularly,  or  are  perhaps  a  little  constipated, 
and  slight  complaint  of  headache  or  languor,  with  loss  of  the  usual 
cheerfulness,  are  often  all  the  permanent  ill  effects  to  be  discerned 
between  the  seizures. 

After  the  hoop  has  been  heard,  the  disease  goes  on  for  about  a  week 
to  increase  in  severity,  the  cough  becoming  more  frequent,  its  paroxysms 
severer  and  more  suffocating,  and  attended  with  more  frequent  hoop. 
After  remaining  stationary  for  ten  days  or  a  fortnight,  it  begins  to 
decline  ;  and  one  of  the  first  indications  of  this  is  usually  afforded  by  a 
diminution  in  the  severity  of  the  nocturnal  exacerbations.  We  next 
find  either  that  the  fits  of  coughing  are  less  frequent ;  or,  though  they 
should  occur  as  often  as  before,  yet  they  are  less  severe,  and  sometimes 
cease  without  the  occurrence  of  a  hoop.  When  on  the  decline,  how- 
ever, exposure  to  the  cold,  neglect  of  the  state  of  the  bowels,  or  mental 
excitement,  will  suffice  in  many  cases  to  bring  back  the  hoop,  and  to 
increase  the  previously  diminished  severity  of  the  attack.  For  the 
most  part,  the  cough  loses  its  spasmodic  character  for  many  days  before 
it  ceases  altogether  ;  and  you  may  even  find  a  child,  otherwise  in  good 
health,  who,  some  six  weeks  after  an  attack  of  hooping-cough,  still  has 
occasional  returns  of  cough,  which  a  slight  cause  would  once  more  con- 
vert  into  an  ailment  with  all  the  characters  of  fully  developed  pertussis. 

Such  is  the  ordinary  course  of  the  disease  in  those  cases  in  which  it 
is  unattended  by  any  complication,  and  does  not  give  rise  to  any  for- 
midable symptom,  but  issues  in  the  complete  recovery  of  the  patient. 
But  even  in  favourable  cases,  its  course  is  often  variously  modified, 
while  these  modifications  derive  additional  importance  from  frequently 
betokening  or  accompanying  some  of  those  serious  complications,  to 
which  the  danger  of  the  disease  is  almost  exclusively  due. 

The  average  duration  of  the  catarrhal  stage  of  hooping-cough,  as 
deduced  from  a  comparison  of  fifty-five  cases,  in  which  the  date  of  the 
occurrence  of  the  first  distinct  hoop  was  ascertained,  was  12.7  days. 
In  nineteen  of  these  cases  the  first  hoop  was  heard  within  seven  days 
from  the  commencement  of  the  catarrhal  symptoms,  and  in  nineteen 
more  cases  during  the  succeeding  seven  days ;  but  the  extreme  limits 
of  the  duration  of  the  premonitory  stage  are  very  wide  apart,  since 
on  one  occasion  it  lasted  only  two  days,  and  on  another,  thirty-five  days. 

But  there  are  many  other  respects  in  which  the  mode  of  onset  of 
hooping-cough  varies,  as  is  clearly  shown  by  the  following  facts  : — 

In  fifty-five  cases  the  average  duration  of  the  catarrhal  stage  was 
12.7  days :  the  extremes  being  2  and  35  days.     In  eighteen  cases  the 


DURATION   OF   THE   CATARRHAL   STAGE   OF   HOOPING-COUGH.  253 

catarrhal  stage  lasted  on  the  average  only  8.3  days,  when  the  cough 
assumed  a  distinctly  paroxysmal  character  :  but  no  hoop  occurred  till 
the  fifteenth  day.  In  four  cases,  after  the  catarrhal  stage  had  lasted 
on  the  average  11.5  days,  the  cough  became  paroxysmal,  but  no  hoop 
occurred  during  the  whole  course  of  the  affection.  In  one  case  the 
cough  had  a  distinctly  paroxysmal  character  from  the  first,  but  no 
hoop  occurred  during  the  whole  course  of  the  affection.  In  six  cases 
the  cough  was  paroxysmal  from  the  outset,  and  continued  so  on  the 
average  9.3  days,  at  the  end  of  which  time  distinct  hoop  accompanied 
it.  In  three  cases  a  distinct  hoop  attended  the  cough  from  the  very 
commencement. 

Some  of  these  may  be  merely  accidental  differences,  but  I  believe 
that  most  of  them  are  by  no  means  unimportant,  and  that  they  depend 
on  causes  with  which  a  little  observation  will  make  you  acquainted. 
My  excuse,  indeed,  for  bringing  before  you  such  dry  detail,  with 
reference  to  hooping-cough,  is,  that  there  is  scarcely  any  other  disease 
of  early  life  concerning  which  we  are  so  much  in  want  of  definite  facts. 
Its  general  features  are  so  obvious,  that  persons  have  not  so  carefully 
observed  those  less  striking  characters  which  yet  are  of  much  moment, 
as  affording  sure  grounds  for  prognosis,  and  trustworthy  indications 
for  the  guidance  of  treatment. 

Unusual  protraction  of  the  catarrhal  stage  of  hooping-cough,  is,  I 
believe,  usually  met  with  either  at  the  commencement  of  an  epidemic 
of  the  disease,  or  towards  its  close.  Epidemic  hooping-cough  very 
frequently  succeeds  to  epidemic  catarrh ;  the  former  disease  becoming 
gradually  developed  out  of  the  latter,  and  the  persistence  of  cough  in 
several  cases  long  after  the  decline  of  all  other  indications  of  catarrh, 
is  often  one  of  the  first  signs  of  the  commencement  of  an  epidemic  of 
hooping-cough.  The  characters  of  hooping-cough,  like  those  of  other 
epidemic  diseases,  often  become  less  marked  towards  the  decline 
of  its  prevalence,  and  we  then  meet  with  cases  in  which  catarrhal 
symptoms  continue  long,  while  the  paroxysms  of  cough  are  slight,  and 
the  hoop  occurs  very  seldom  and  not  severely.  It  may  be  laid  down 
as  a  general  rule,  that  those  cases  in  which  the  catarrhal  stage  is  of 
long  continuance,  seldom  become  severe  during  their  subsequent  pro- 
gress, and  the  same  holds  good  with  reference  to  the  majority  of  those 
cases  in  which  the  hoop  does  not  come  on  until  after  the  cough  has 
for  some  time  assumed  a  paroxysmal  character.  There  are,  however, 
some  instances,  which  we  shall  hereafter  have  to  notice,  where  the 
long  duration  of  the  paroxysmal  and  suffocative  character  of  the  cough, 
unattended  by  any  hoop,  is  a  sign  of  the  peculiar  intensity  of  the 
disease,  rather  than  of  its  mildness  :  on  the  other  hand,  the  preterna- 
tural shortness  of  the  catarrhal  stage,  or  its  total  absence,  is  not  of 
itself  any  proof  that  the  disease  will  be  more  than  usually  severe.  It 
is  usually  observed  in  very  young  children,  who,  as  I  have  already  told 
you,  are  but  little  liable  to  catarrhal  affections,  and  who  are  not  so 
often  attacked  by  hooping-cough  as  older  children.  Sometimes,  how- 
ever, when  other  children  in  the  same  family  are  suffering  from  it, 
they  contract  the  disease  apparently  by  contagion,  and  in  that  case  it 
frequently  happens  that  no  purely  catarrhal  symptoms  precede  it,  but 


254  VARIATIONS   IN    THE   MODE   OF   ONSET   OP   THE   DISEASE. 

that  the  cough  from  the  first  presents  a  paroxysmal  character,  and  that 
it  very  soon  becomes  attended  with  a  distinct  hoop. 

Instead  of  coming  on  with  catarrh  of  moderate  intensity,  hooping- 
cough  sometimes  sets  in  with  great  fever,  dyspnoea,  and  many  symptoms 
of  severe  bronchitis  ;  though  the  results  of  auscultation  do  not  indicate 
such  'serious  disease  as,  judging  from  the  amount  of  constitutional 
disturbance,  we  should  expect  to  discover.  In  such  cases  it  is  only  on 
the  subsidence  of  the  acute  symptoms,  which  usually  give  way  speedily 
under  treatment,  that  the  real  nature  of  the  disease  becomes  apparent. 
We  then  observe,  however,  that  while  the  child  in  all  other  respects 
improves,  the  cough  continues  unabated,  that  it  soon  grows  more 
severe,  returning  in  paroxysms,  and  being  attended  before  long  by  the 
characteristic  hoop.  Besides  these  'cases,  there  are  others,  though 
much  less  common,  in  which,  though  the  catarrhal  symptoms  are  not 
unusually  severe,  the  child  yet  has  paroxysms  of  dyspnoea,  which  gene- 
rally come  on  at  night,  and  may  excite  much  apprehension  on  the 
part  of  the  parents.  The  attacks  do  not  appear  to  be  induced  by  any 
previous  fit  of  coughing,  and  after  lasting  from  half  an  hour  to  an 
hour,  they  pass  off  of  their  own  accord,  leaving  the  child  free  for  many 
hours  together,  and  probably  not  returning  until  the  following  night. 
While  the  child  continues  subject  to  them,  auscultation  discovers  no 
sign  of  serious  mischief  in  the  lungs ;  but  in  proportion  as  the 
paroxysms  of  the  cough  increase  in  distinctness,  and  the  hoop  becomes 
established,  the  fits  of  dyspnoea  diminish,  and  in  the  course  of  a  few 
days  entirely  disappear. 

Some  days  usually  elapse  after  the  general  characters  of  the  disease 
have  become  well  marked,  before  it  reaches  its  acme,  and  during  this 
time  its  nocturnal  paroxysms  generally  increase  in  a  greater  ratio, 
both  as  to  frequency  and  severity,  than  those  which  occur  by  day. 
Such,  at  leaft,  was  the  course  of  the  disease  in  thirty-eight  out  of 
forty-seven  cases  in  which  this  point  was  especially  noticed.  The  noc- 
turnal exacerbation  is  sometimes  so  marked,  that  the  fits  of  coughing 
are  not  only  severer,  but  are  actually  more  numerous  by  night-time 
than  by  day.  In  very  mild  cases  of  hooping-cough  there  is  but  little 
difference  between  the  frequency  and  severity  of  the  paroxysms  at  night- 
time and  by  day  ;  and  in  other  instances,  while  the  child  rests  quietly 
through  the  greater  part  of  the  night,  there  is  yet  a  marked  aggrava- 
tion of  the  cough  on  first  lying  down  at  night,  and  on  first  waking  in 
the  morning.  When  the  exacerbations  occur  at  these  two  periods,  the 
evening  exacerbation  is  often  induced  by  the  child  being  removed  to  a 
bed-room  less  warm  than  the  apartment  in  which  it  spends  the  day, 
while  the  morning  attack  results  from  the  accumulation  of  mucus  in 
the  bronchi  during  the  hours  of  sleep. 

Neither  of  these  causes,  however,  is  the  sole  occasion  of  the  increased 
severity  of  the  disease  at  night,  nor  is  the  occurrence  peculiar  to  hoop- 
ing-cough, but  is  observed  also  in  asthma,  and  in  many  other  affections 
of  the  respiratory  organs  in  adults.  The  severity  of  the  nocturnal 
paroxysms  is  often  a  very  good  criterion  of  the  general  severity  of  the 
disease  ;  and  any  exacerbation  of  the  disease  is  usually  attended  with 
special  exacerbation  of  the  nocturnal  paroxysms,  and  not  merely  by 


CAUSE   OP   THE   HOOP  WHICH   ATTENDS   THE  FITS   OF   COUGHING.      255 

more  frequent  coughing  and  hooping,  but  likewise  by  a  marked  increase 
of  dyspnoea.  On  the  other  hand,  a  diminution  of  the  nocturnal  exacer- 
bations is  one  of  the  most  frequent  indications  that  the  disease  has 
begun  to  lose  something  of  its  previous  severity,  and  the  cough  often 
ceases  entirely  at  night  for  some  time  before  it  disappears  completely 
during  the  day-time. 

Cough,  preceded  by  catarrhal  symptoms,  aggravated  in  paroxysms, 
assuming  a  suffocative  character,  and  attended  with  a  peculiar  sonorous 
inspiration  called  a  hoop,  were  said  to  be  the  characteristics  of  this 
disease.  The  last  two  of  these  phenomena  are  the  special  results  of 
the  nervous  element  which  goes  to  make  up  the  very  compound  charac- 
ter of  hooping-cough.  Hence,  in  those  cases  which  are  very  mild, 
there  is  so  little  spasm  of  the  glottis,  that  air  enters  freely  when  the 
child  draws  breath  after  a  fit  of  coughing,  and  the  hoop  is  occasional 
and  faint,  while  it  is  still  more  seldom  that  the  cough  displays  that 
suffocative  character  which,  when  severe,  constitutes  one  of  its  most 
formidable  peculiarities. 

None  of  the  phenomena  of  this  disease  call  for  such  close  observa- 
tion as  the  hoop  from  which  it  derives  its  name.  Its  occurrence  indi- 
cates on  the  one  hand  the  existence  of  spasm  of  the  glottis ;  and  hence 
in  those  cases  which  are  very  slight,  it  takes  place  but  seldom,  while 
it  hardly  ever  comes  on  until  the  disease  has  lasted  a  certain  time,  and 
acquired  a  certain  degree  of  intensity.  It  shows,  however,  on  the 
other  hand,  that  air  does  enter,  when  the  child  endeavours  to  inspire, 
and,  therefore,  in  cases  of  severe  hooping-cough,  a  loud,  long-drawn, 
sonorous  hoop,  instead  of  adding  to  our  apprehension,  tends  rather  to 
quiet  it,  for  it  assures  us  that  the  spasm  does  not  amount  to  actual 
closure  of  the  glottis,  and  that,  for  this  time  at  least,  the  child  will  not 
choke  in  the  fit  of  coughing.  I  have  already  mentioned  to  you  that  the 
nocturnal  dyspnoea  which  excites  anxiety  in  some  cases  while  hooping- 
cough  is  coming  on,  may  disappear  altogether  when  the  disease  has 
asumed  its  regular  type,  and  the  hoop  has  become  loud  and  distinct. 
Just  in  the  same  wTay,  the  violent,  suffocative  character  of  the  paroxysm 
often  abates,  the  fits  of  coughing  become  fewer,  and  the  dyspnoea  grows 
less  urgent  after  the  hoop  has  become  developed. 

But  if  the  disease  should  increase  in  severity,  cough  comes  on  more 
frequently,  and  the  paroxysms  are  of  longer  continuance,  so  that  the 
face  grows  quite  livid  before  they  pass  away.  The  pauses  in  the  fit  are 
now  no  longer  marked  by  the  sonorous  hoop,  but,  after  a  momentary 
cessation,  the  cough  recommences ;  and  though  when  at  length  the 
attack  passes  off  a  hoop  is  heard,  it  is  more  stridulous  than  it  used  to 
be,  though  not  so  loud.  Each  paroxysm  of  cough  is  now  preceded  and 
followed  by  marked  dyspnoea,  and  the  child  has  scarcely  recovered 
from  one  attack  before  another  comes  on.  The  hoop  now  sometimes 
disappears  altogether,  or  is  very  occasional,  very  short,  and  suppressed ; 
and  then  the  cough  itself  loses  its  former  character ;  the  child  dreads 
its  approach  much,  and  tries  to  suppress  it,  but  in  vain ;  the  whole 
frame  labours  with  the  convulsive  efforts,  but  no  sound  is  produced:  the 
larynx  is  now  completely  closed ;  violent,  but  fruitless,  expiratory 
efforts  are  made,  as  in  some  of  the  worst  cases  of  spasmodic  croup,  till 


256  VARIATIONS   IN   ITS   DISTINCTNESS,   AND   THEIR'  IMPORT. 

general  convulsions  come  on  ;  or  at  length  the  spasmodic  constriction 
yields,  and  the  effort  at  expiration  is  successful.  The  spasm  over,  the 
child  once  more  draws  breath,  but  it  seems  quite  exhausted  bj  the  vio- 
lence of  the  struggle;  while  sometimes,  before  it  has  recovered  from 
this  seizure,  another,  and  then  another,  succeed,  till  one  at  length 
proves  fatal. 

When  the  disease  has  approached  to  this  degree  of  intensity,  we 
should  rejoice  to  hear  the  loud,  long  hoop  again,  which  would  be  a  sure 
token  of  some  diminution  in  the  suffocative  character  of  the  cough.  We 
should  next  find  that  as  the  hoop  regained  its  former  character,  those 
more  numerous  but  less  distinct  efforts,  wrhich  the  child  had  made  before, 
would  be  merged  in  the  single  prolonged  inspiration.  The  dyspnoea 
would  next  diminish,  and  then  the  severity  of  each  paroxysm  would 
grow  less  ;  and  then  they  would  not  recur  so  often,  and  the  hoop  would 
be  less  loud,  and  the  night  attacks  less  frequent.  If  amendment  were 
to  continue,  the  attacks  would  become  more  brief,  and  they  would  some- 
times pass  off  without  any  hoop,  while  the  mucous  expectoration  wTould 
become  more  copious;  next  the  hoop  would  altogether  cease,  but  the 
cough  would  continue  to  recur  in  paroxysms,  and  to  present  something 
of  its  old  suffocative  character;  and  then  this  too  would  cease,  though 
cough  might  still  continue  for  a  time  longer. 

The  variations  in  the  course  of  hooping-cough  which  I  have  now 
described,  depend  for  the  most  part  either  on  the  greater  or  less  in- 
tensity of  the  disease,  or  on  some  idiosyncrasy  of  the  patient,  or  on 
some  peculiarity  in  the  epidemic  constitution  of  the  year.  There  are, 
however,  other,  and  some  of  them  much  more  important  changes  in  its 
symptoms  and  its  course,  which  result  from  hooping-cough  becoming 
complicated  with  another  disease.  Of  these  complications,  by  far  the 
most  frequent  and  most  perilous  are  those  which  it  presents  with  bron- 
chitis and  pneumonia,  on  the  one  hand;  and  with  convulsions,  conges- 
tion of  the  brain,  or  hydrocephalus,  on  the  other.  Their  importance, 
too,  is  greatly  increased  by  there  being  no  period  of  the  disease  to  which 
we  can  look  as  bringing  with  it  any  immunity  from  either ;  but,  from 
the  commencement  of  the  cough  to  its  complete  disappearance,  we  are 
at  any  moment  exposed  to  the  risk  of  disease,  either  of  the  lungs  or  of 
the  brain,  converting  a  trivial  into  a  most  formidable  affection.1 

1  Of  27  children  who  died  of  hooping-cough  under  my  care,  13  perished  in  conse- 
quence of  the  supervention  of  bronchitis  or  pneumonia,  14  from  congestion  of  the 
brain,  from  convulsions  coming  on  in  a  fit  of  coughing,  or  from  hydrocephalus. 

Reckoning  the  commencement  of  the  disease  from  the  first  distinct  hoop,  or  first 
appearance  of  well-marked  paroxysmal  character  of  the  cough,  it  appears  that  of  24 
cases  in  which  this  point  was  noted — 
Dying  through  the  lungs.     Dying  through  the  brain.         Total.  Dying  within 

0       1        ., 1        7  days. 

2       3       5       14  days. 

1       2       3       21  days. 

0       1       

1       1       

1  0 

2  2  

1  1  

4  1  

12  12 


1     , 

28  davs. 

2       

1       

4       ....... 

2       

, 8  weeks. 

5       

24 

from  8 

weeks  to 
3  mcnths. 

BRONCHITIS.  257 

The  circumstances  under  which  hooping-cough  becomes  associated 
until  other  affections  of  the  respiratory  organs  are  very  various.  Some- 
times, as  I  have  already  mentioned,  rather  severe  bronchitic  symptoms, 
frequent,  short  cough,  and  considerable  dyspnoea,  precede  the  full  de- 
velopment of  the  disease.  This  occurrence  is  oftenest  met  with  at  the 
commencement  of  epidemics  of  hooping-cough,  or  in  children  the  mucous 
membrane  of  whose  air-tubes  may  be  supposed  to  have  acquired  a  pecu- 
liar susceptibility  from  many  previous  bronchitic  seizures.  On  the  whole, 
however,  these  are  not  the  cases  which  need  excite  our  greatest  solici- 
tude, for  the  constitutional  symptoms,  which  are  generally  out  of  all 
proportion  to  the  amount  of  the  local  mischief,  usually  subside  in  the 
course  of  a  few  days,  just  as  we  often  observe  to  be  the  case  with 
epidemic  influenza  in  the  adult;  and  as  the  characteristic  cough  and 
hoop  come  on,  all  cause  for  anxiety  disappears. 

Those  cases  are  in  general  much  more  serious  in  which  the  symptoms 
of  bronchitis  or  pneumonia  come  on  after  the  cough  has  assumed  the 
characters  of  hooping-cough.  This  complication  sometimes  occurs  very 
early  in  the  course  of  the  disease,  and  then  the  bronchitis  and  hooping- 
cough  appear  to  be  developed  almost  simultaneously.  For  a  day  or  two, 
perhaps,  a  hoop  has  been  heard  accompanying  the  cough  at  intervals, 
and  nothing  has  appeared  to  indicate  that  the  attack  will  be  unusually 
severe,  when  all  the  symptoms  suddenly  become  very  much  aggravated ; 
the  skin  grows  hot ;  the  respiration  and  pulse  become  very  much  hur- 
ried, and  this  increase  in  their  frequency  is  permanent,  though  much 
greater  at  one  time  than  at  another.  The  cough  at  the  same  time 
becomes  more  frequent  and  more  severe,  and  the  hoop  is  more  violent ; 
but  the  cough  is  almost  entirely  unattended  with  expectoration,  or  if  a 
little  mucus  be  spit  up  it  is  almost  always  streaked  with  blood.  Though 
very  violent,  the  fits  of  coughing  are  not  very  long,  and  they  seldom 
or  never  end  with  vomiting.  The  ear  detects  mucous  rale  through  nearly 
the  whole  of  both  lungs :  on  a  deep  inspiration,  still  smaller  sounds  are 
heard,  for  inflammation  has  attacked  the  minuter  air-tubes ;  and  the 
case  is  one  of  hooping-cough  complicated  with  capillary  bronchitis. 

Supposing  the  disease  to  continue,  the  cough  will  often  in  a  day  or 
two  lose  its  characteristic  hoop,  an  occurrence  which  you  will  likewise 
observe  in  the  course  of  many  other  intercurrent  febrile  or  inflamma- 
tory affections  that  may  supervene  during  an  attack  of  hooping-cough. 
The  cough,  too,  may  become  less  frequent,  or  may  lose  its  paroxysmal 
character,  though  it  will  still  appear  to  cause  much  suffering.  The 
respiration  will  increase  in  frequency,  the  child  constantly  labouring 
for  breath,  and  being  distressed  by  the  slightest  movement,  since  that 
adds  to  its  dyspnoea.  In  one  little  child  two  years  old,  the  inspirations 
two  days  before  her  death  were  130  in  the  minute,  and  then  on  the 
following  day  they  sank  to  80;  but  her  feet  were  now  cold,  her  face 
was  livid,  and  her  pulse  very  feeble.  It  was  she,  of  whose  lung  I 
showed  the  drawing  some  days  since,  illustrative  of  vesicular  bronchitis ; 
and  her  case  might  be  taken  as  a  type  of  those  in  which  acute  bron 
chitis  comes  on  at  an  early  stage  of  hooping-cough. 

Death  takes  place  more  speedily  in  cases  of  this  kind  than  under  any 
other  form  of  affection  of  the  lungs  which  comes  on  in  the  course  . 

17 


258        COMPLICATION   OF   HOOPING-COUGH — BRONCHITIS — PNEUMONIA. 

hooping-cough.  I  have  seen  a  child  die  on  the  sixth  day  from  the  first 
appearance  of  any  indication  that  the  disease  was  other  than  a  very 
mild  attack  of  hooping-cough.  It  will  not  surprise  you  that  the  fatal 
event  should  take  place  so  speedily,  if  you  bear  in  mind,  that  after 
death  we  discover  either  intense  injection,  even  of  the  smaller  bronchi, 
with  copious  effusion  of  pus  into  their  cavities,  or  very  extensive  vesi- 
cular bronchitis,  or  both  conditions  together. 

But  it  is  not  only  at  the  outset  of  an  attack  of  hooping-cough  that 
we  encounter  the  danger  of  its  becoming  complicated  with  other  diseases 
of  the  lungs.  Exposure  to  cold,  or  damp,  may  at  almost  any  period 
induce  an  exacerbation  of  the  cough,  or  a  distinct  attack  of  bronchitis. 
If,  however,  the  disease  have  already  lasted  for  some  ten  days  or  a 
fortnight,  without  having  presented  any  grave  features,  such  intercur- 
rent bronchitic  seizures  are  usually  very  tractable. 

As  a  general  rule,  those  cases  have  appeared  to  me  to  be  far  more 
serious  in  which  bronchitic  symptoms  become  developed  of  their  own 
accord  out  of  severe  hooping-cough.  In  such  cases  there  has  usually 
been  a  gradual  increase  in  the  child's  sufferings ;  the  cough  growing 
more  frequent,  and,  though  not  more  violent,  yet  evidently  occasioning 
the  child  greater  suffering;  while  the  hoop  is  unchanged  in  its  cha- 
racter. At  the  same  time  the  child  seems  overwhelmed  by  the  disease ; 
its  face  is  anxious  and  puffed,  the  eyes  are  much  suffused,  the  skin 
usually  dry  and  hot ;  dyspnoea  is  no  longer  confined  to  the  periods  just 
before  and  just  after  a  fit  of  coughing,  but  the  respiration  is  habitually 
wheezing,  hurried,  and  rather  irregular.  The- ear,  at  the  same  time, 
detects  mucous  or  subcrepitant  rale  through  the  whole  of  both  lungs. 
Such  cases  are  seldom  very  rapid  in  their  course.  The  symptoms,  after 
exciting  our  solicitude  for  a  week,  ten  days,  or  a  fortnight,  may  gradu- 
ally abate  in  severity,  and  the  disease  may  run  the  remainder  of  its 
course  slowly,  but  safely.  If  the  case  should  have  an  unfavourable 
issue,  this  sometimes  takes  place  speedily,  owing  to  the  supervention  of 
cerebral  symptoms;  and  the  child  then  dies  during  a  paroxysm  of 
coughing.  Or  the  minute  bronchi  may  become  involved  in  the  inflam- 
matory mischief;  the  case  may  assume  the  characters  of  pneumonia, 
and  bronchial  breathing  and  dulness  on  percussion  may  reveal  during 
the  patient's  lifetime  the  nature  of  the  mischief  which  will  be  disclosed 
on  an  examination  after  death. 

In  a  still  more  numerous  class  of  cases,  the  disease  retains  its  chronic 
character  to  the  last,  and  presents  little  or  no  variation  from  day  to  day. 
The  violence  of  the  cough,  and  the  frequency  of  its  return,  sometimes 
continue  unabated,  though  often  they  undergo  a  marked  diminution. 
The  respiration  grows  more  hurried  than  before,  the  fever  becomes 
exacerbated,  and  the  emaciation  extreme ;  while  the  child's  strength  is 
still  more  enfeebled  by  the  supervention  of  a  troublesome  diarrhoea, 
which  no  remedies  are  adequate  to  restrain.  Death  at  length  takes 
place,  sometimes  from  pure  exhaustion ;  and  the  transition  from  sleep 
to  death  is  so  gentle  as  to  be  almost  imperceptible.  At  other  times  an 
increase  of  the  symptoms  of  bronchitis  or  pneumonia  becomes  apparent 
for  two  or  three  days  previously;  or  in  other  cases  the  child  dies 
exhausted  in  a  fit  of  coughing,  or  convulsions  take  place  a  few  hours 
before  death,  and  the  patient  dies  convulsed,  or  comatose. 


CEREBRAL   CONGESTION.  259 

1  The  complication  of  hooping-cough  ivith  serious  disorder  of  the  nervous 
system  is  almost  as  frequent  as  its  association  with  grave  mischief  in 
the  lungs  and  air-tubes,  and  even  more  dangerous  and  perplexing. 
Hazard  from  this  source  attends  alike  the  onset  of  the  disease,  its  acme, 
and  decline ;  and  the  mode  in  which  the  danger  presents  itself  is  no 
less  variable  than  are  the  seasons  of  its  occurrence.  The  nervous 
system  sometimes  suffers  so  severely  from  the  very  first,  that  death 
takes  place  almost  before  the  disease  has  had  time  to  assume  its  usual 
characters.  At  other  times  hooping-cough  comes  on  naturally ;  its  two 
elements,  the  bronchitic  and  the  nervous  (if  I  may  be  allowed  the  ex- 
pression), increase  daily  in  intensity,  till  all  at  once  the  symptoms  of 
the  former  recede,  and  are  almost  lost  in  those  of  the  latter,  which  in 
a  day  or  two  bring  on  the  fatal  termination  of  the  case.  Or  lastly,  no 
symptoms  referrible  to  the  nervous  system  call  for  our  solicitude  until 
after  the  hooping-cough  has  continued  many  weeks ;  but  then  the  long 
continuance  of  the  disease  seems  to  excite  mischief  in  the  brain,  and 
death  overtakes  the  patient  when  we  had  already  begun  to  hope  that 
nothing  more  than  time  was  needed  to  perfect  his  cure. 

Danger  from  this  cause  sometimes  assumes  the  form  of  simple  con- 
gestion of  the  brain :  drowsiness  is  followed  by  convulsions,  and  these 
are  succeeded  by  fatal  coma.  In  other  instances  the  spinal  system  of 
nerves  becomes  excited  to  more  tumultuous  reaction ;  and  carpopedal 
contractions,  and  attacks  of  spasm  of  the  glottis,  become  superadded  to 
frequently  recurring  general  convulsions ;  while  in  some  cases  the  long 
continuance  of  hooping-cough  gives  rise  to  the  development  of  acute 
hydrocephalus.  The  time  will  not  be  lost  which  we  may  spend  in  the 
examination  of  each  of  these  various  modes  in  which  hooping-cough 
becomes  complicated  with  disorder  of  the  nervous  system. 

In  very  young  children,  and  in  those  in  whom  the  process  of  denti- 
tion is  still  going  on  at  the  time  of  their  becoming  affected  with  hooping- 
cough,  the  symptoms  of  disturbance  of  the  nervous  system  are  some- 
times formidable  even  from  the  outset.  In  such  cases  the  preliminary 
catarrh  is  usually  of  short  duration,  and  the  cough,  though  not  very 
frequent,  yet  assumes  a  paroxysmal  character  almost  from  the  first. 
Each  fit  of  coughing  is  extremely  violent  and  suffocative  ;  it  lasts  for 
several  minutes,  is  not  attended  by  any  distinct  hoop,  nor  followed  by 
vomiting,  but  ceases  apparently  from  the  child  being  too  exhausted  to 
make  any  further  effort.  In  the  intervals  of  the  cough  the  face  is 
flushed,  the  eyes  are  suffused,  and  the  child  is  very  drowsy,  and  averse 
to  being  disturbed — a  condition  which  is  manifestly  increased  by  each 
paroxysm  of  coughing.  When  the  cough  comes  on,  the  flush  of  the 
face  deepens  to  a  livid  hue,  the  pupils  become  dilated,  convulsions  seem 
impending  and  at  length  come  on,  and  though  but  of  short  continuance, 
yet  they  often  leave  the  child  in  a  state  of  profound  stupor.  This  state 
seldom  lasts  long :  sometimes  the  effort  at  coughing  brings  on  a  fatal 
convulsive  seizure,  at  other  times  the  cough  does  not  return,  but  con- 
vulsions recur  independently  of  it,  and  in  twenty- four  or  thirty-six  hours 
from  their  first  occurrence  the  child  dies. 

No  cases  of  hooping  cough  run  so  surely  or  so  speedily  as  these  to  a 
fatal  termination,  which  even  the  most  judicious  treatment  will  often 


260  HEAD    SYMPTOMS   SOMETIMES   COME   ON   GRADUALLY. 

fail  to  prevent.  I  have  seen  death  take  place  in  less  than  a  week  from 
the  commencement  of  the  cough,  and  have  known  several  instances  of 
its  occurrence  long  before  the  lapse  of  a  fortnight. 

The  circumstance  of  the  cough  having  run  its  course  naturally  up  to 
a  certain  point,  affords,  however,  no  guarantee  against  the  supervention 
of  a  danger  similar  to  that  which  we  have  just  been  contemplating.  It 
is,  indeed,  but  seldom  that  any  case  which  for  the  first  ten.  days  or  fort- 
night has  been  mild  in  character,  afterwards  presents  these  alarming 
symptoms  of  cerebral  disturbance  ;  for  in  most  instances  the  cough  will 
have  been  severe  from  the  commencement,  the  paroxysms  frequent  and 
of  long  continuance,  the  hoop  loud,  each  attack  terminating  with  vomit- 
ing, and  the  return  of  each  being  much  dreaded  by  the  child.  In  all 
this,  however,  there  is  nothing  to  direct  special  attention  to  the  head, 
and  the  approach  of  the  new  danger  is  not  always  very  obvious.  Some- 
times the  first  indication  that  the  head  suffers  is  afforded  by  the  in- 
creased irritability  of  the  stomach,  which  becomes  almost  unable  to 
retain  food  or  drink.  And  here  let  me  urge  upon  you  the  importance 
of  duly  estimating  the  signification  of  this  symptom.  Vomiting,  inde- 
pendent of  the  fits  of  coughing,  if  it  persist  for  above  twenty-four  hours, 
and  be  not  referrible  to  the  remedies  you  are  employing,  nor  connected 
with  obvious  gastric  disorder,  should  always  excite  your  solicitude,  and 
direct  your  attention  most  anxiously  to  the  head. 

At  other  times,  either  in  connection  with  this  irritability  of  the 
stomach,  or  even  independently  of  it,  the  child  is  observed  to  become 
daily  more  heavy  and  drowsy,  and  averse  to  movement ;  complaining 
of  headache  if  able  to  talk,  and  appearing  overwhelmed  by  the  disease 
to  a  greater  degree  than  can  be  accounted  for  either  by  the  severity  of 
the  paroxysms  or  the  frequency  of  their  recurrence.  This  condition  is 
generally  succeeded  by  aggravation  of  the  dyspnoea  both  before  and 
after  each  fit  of  coughing,  the  respiration  sometimes  not  regaining  its 
proper  frequency  during  the  interval  between  their  return,  though 
auscultation  fails  to  detect  any  adequate  cause  for  this  hurried  breathing. 
In  some  instances  the  hoop  still  continues  as  loud  as  before ;  but  if 
that  be  the  case,  the  cough  grows  harder,  and  hardly  any  mucus  is 
expectorated;  while  streaks  of  blood  are  seen  in  the  matters  rejected 
by  vomiting.  It  happens  more  frequently,  however,  that  these  symp- 
toms are  associated  with  a  more  or  less  complete  suppression  of  the 
hoop ;  the  cough  losing  something  of  its  distinctly  paroxysmal  cha- 
racter, but  becoming  more  suffocative;  the  child,  on  each  occasion  of 
its  return,  vainly  striving  to  suppress  it.  A  convulsive  seizure- now,  in 
some  cases,  supervenes  on  an  effort  to  cough,  and  in  this  the  child 
expires ;  or  the  fatal  convulsion  may  come  on  to  all  appearance  cause- 
lessly :  or,  more  frequently,  the  first  convulsion  does  not  occasion  death, 
but  it  leaves  the  child  in  a  comatose  condition,  which  is  interrupted  by 
the  frequent  return  of  convulsions,  one  of  which  at  length  proves  fatal. 

It  happens  sometimes  that  children  who  are  labouring  under  severe 
hooping-cough  are  suddenly  seized,  during  a  paroxysm  of  coughing, 
with  a  fit  of  convulsions  ;  and  they  may  die  in  this  fit,  even  though  they 
had  not  previously  seemed  to  suffer  from  any  serious  disorder  of  the 
nervous  system.     Death  in  such  cases  takes  place  as  the  result  of  spas- 


GREAT  DANGER   WHEN   CONVULSIONS   RETURN   FREQUENTLY.  261 

modic  closure  of  the  larynx,  and  consequent  congestion  of  the  brain : 
you  watch  for  a  few  moments  the  fruitless  expiratory  eiforts  of  the 
child,  and  then  all  is  over,  just  as  in  many  fatal  cases  of  spasmodic 
croup.  The  relation  between  hooping-cough  and  spasmodic  croup, 
indeed,  is  sometimes  very  apparent;  and  you  may  observe,  after  some 
unusually  violent  fit  of  coughing,  the  thumbs  drawn  into  the  palms,  the 
hand  flexed  upon  the  wrist,  or  the  great  toe  drawn  apart  from  the 
others.  At  first,  probably,  the  symptoms  will  be  slight,  and  will  soon 
pass  away ;  but  their  import  is  most  serious.  You  will  expect  soon  to 
see  other  and  graver  indications  of  the  disturbance  of  the  nervous  sys- 
tem,— if,  indeed,  they  be  not  already  present.  It  is  especially  in  cases 
of  this  sort  that  you  will  observe  a  degree  of  dyspnoea  which  you  can- 
not explain ;  and  that  the  child  will  seem  to  make  the  most  violent 
efforts  to  suppress  the  cough, — efforts  which  are  really  involuntary,  and 
are  the  result  of  the  spasmodic  closure  of  the  glottis,  which  is  sure,  if 
complete  and  long  continued,  to  be  followed  by  an  attack  of  convul- 
sions. If  treatment  fail,  the  carpopedal  contractions  will  become  per- 
manent, the  eyes  will  close  but  partially,  the  breathing  will  grow 
extremely  unequal  and  irregular,  as  well  as  hurried,  the  hoop  will  no 
longer  be  heard,  and  the  cough  itself  will  yield  only  a  kind  of  smothered 
sound.  The  surface  will  grow  quite  livid,  in  consequence  of  the 
extremely  imperfect  performance  of  the  respiratory  function  ;  the  child 
will  sink^into  a  state  of  stupor,  in  which  it  will  lie  with  dilated  pupils 
and  constant  twitching  of  the  muscles  of  its  face,  till  a  great  effort  to 
cough  comes  on,  and  passes  almost  at  once  into  a  convulsive  paroxysm. 
The  fits  at  length  come  on  independent  of  any  attempt  at  coughing, 
and  once  I  saw  a  considerable  degree  of  stiffness  of  the  whole  spinal 
column  precede  for  twelve  hours  the  death  of  a  little  boy,  who  fell  a 
victim  to  hooping-cough  thus  sadly  complicated  with  disorder  of  the 
nervous  system. 

It  would  be  only  by  the  recital  of  cases  that  I  could  bring  before 
your  notice  each  minute  variation  in  the  characters  of  these  formidable 
complications  of  hooping-cough v;  and  for  such  details  there  remains  no 
time  to-day.  There  are  two  points,  however,  bearing  on  this  subject, 
which  I  am  most  anxious  to  impress  on  your  memory.  One  is,  that 
the  supervention  of  dyspnoea,  or  the  sudden  aggravation  of  difficulty  of 
breathing  which  had  existed  previously,  is  often  one  of  the  earliest  indi- 
cations of  serious  affection  of  the  nervous  system.  The  other  point,  on 
which  I  shall  have  to  dwell  at  our  next  lecture,  is,  that  if,  mistaking 
the  import  of  this  nervous  dyspnoea,  you  direct  your  treatment  to  some 
imagined  mischief  in  the  chest,  and  make  free  use  of  antimony  and 
other  depressing  medicines,  you  will  aggravate,  instead  of  relieving, 
the  difficulty  of  breathing ;  and, — the  irritability  of  the  nervous  system 
increasing  in  proportion  as  the  respiration  becomes  impaired, — you  will 
hasten  the  occurrence  of  convulsions,  and  of  that  formidable  train  of 
symptoms  which  we  have  just  been  contemplating. 

I  mentioned  that  true  tubercular  hydrocephalus  is  now  and  then  met 
with  as  a  complication  of  hooping-cough.  Fortunately  it  is  not  of  fre- 
quent occurrence,  though  the  danger  of  its  supervention  should  never 
be  forgotten  in  the  case  of  weakly  children  who  have  long  suffered  from 


262  ACUTE   HYDROCEPHALUS. 

severe  hooping-cough.  Two  instances  of  it  have  come  under  my  obser- 
vation ;  but  in  one  of  these  cases  the  cerebral  disease  was  associated 
with  such  a  large  amount  of  mischief  in  the  chest  as  would  of  itself 
have  sufficed  to  destroy  the  child.  The  other  case  was  of  much  import- 
ance, as  shewing  the  insidious  manner  in  which  fatal  disease  may  steal 
on,  presenting  little  to  excite  serious  apprehension  till  long  after  the 
possibility  of  doing  good  has  passed  away.  The  patient,  a  boy  five 
years  old,  of  a  phthisical  family  on  his  mother's  side,  was  attacked  by 
hooping-cough,  from  which  he  suffered  severely.  The  disease  was 
attended  with  great  dyspnoea,  with  general  oedema  and  great  lividity 
of  the  surface.  No  auscultatory  signs  of  serious  mischief  in  the  lungs 
existed  at  any  time ;  but  the  oppression  of  breathing  was  so  consider- 
able, and  the  child  seemed  so  completely  overwhelmed  by  the  disorder, 
that  I  feared  he  would  not  recover.  After  he  had  suffered  from  the 
cough  for  about  five  weeks,  and  three  weeks  before  his  death,  matters 
seemed  to  take  a  more  favourable  turn ;  his  cough  diminished  greatly 
both  in  frequency  and  severity,  and  his  strength  returned  under  a  tonic 
plan  of  treatment.  He  still,  however,  continued  low-spirited,  and  very 
much  disposed  to  sleep ;  and  this  condition  of  depression  progressively 
increased,  until,  about  a  week  before  his  death,  he  sank  into  a  state  of 
complete  stupor ;  but  no  convulsions  occurred  either  as  precursors  of 
the  stupor  or  during  its  continuance.  He  lay  on  his  back,  either 
sleeping,  or  in  a  state  of  stupor,  from  which,  however,  he  could  be  par- 
tially roused,  when  his  pupils,  before  contracted,  would  become  suddenly 
dilated  to  the  full,  and  he  would  stare  wildly  about  for  a  few  moments : 
the  pupils  would  then  oscillate  for  a  short  time  between  dilatation  and 
contraction,  but  soon  revert  to  their  former  contracted  condition.  The 
bowels  were  not  constipated  at  any  time,  neither  did  vomiting  occur, 
and  the  pulse  continued  frequent  till  within  a  day  or  two  of  his  death. 
Strabismus  came  on  a  day  or  two  before  he  died,  and  two  days  before 
his  death  deglutition  became  difficult,  and  he  began  to  make  slight 
automatic  movements  with  his  hands  and  arms.  Paroxysms  of  cough 
continued  to  recur  to  the  very  last:  they  were  suffocative  in  character, 
but  unattended  by  hoop.  At  the  end  of  the  eighth  week  from  the  com- 
mencement of  his  cough,  the  child,  who  was  extremely  emaciated,  died 
quietly. 

After  death,  the  membranes  of  the  brain  were  found  much  congested  ; 
there  was  a  large  quantity  of  fluid  in  the  ventricles ;  the  central  parts 
of  the  brain  were  diffluent,  and  its  lower  parts  were  likewise  considerably 
softened.  The  membranes  at  the  base  of  the  brain  presented  an  opales- 
cent appearance,  and  were  bestudded  with  numerous  minute  granules, 
while  about  the  optic  nerves  they  were  greatly  thickened  and  infiltrated 
with  that  hyaline  matter  to  which  I  have  often  called  your  attention. 

There  was  much  congestion  of  the  bronchi  and  pulmonary  substance. 
The  lungs  contained  a  good  deal  of  tubercle,  mostly  in  the  state  of  grey 
granulations,  and  a  small  cavity  occupied  the  lower  part  of  the  left 
upper  lobe. 

Many  points  of  importance  connected  with  the  history  of  hooping- 
cough  remain  for  our  examination  before  we  can  proceed  to  consider 
its  treatment ;  but  all  of  these  must  be  reserved  till  our  next  meeting. 


HOOriNG-COUGH   CONTINUED.  263 


LECTURE  XXIII. 


Hooping-Cough,  continued. — Complications  with  diarrhoea  and  intestinal  disorder — 
with  great  irritability  of  the  stomach — with  measles  and  varicella. — Duration  of  the 
disease. — Relapses. — Influence  of  age,  sex,  season,  &c.  in  its  production. — Post- 
mortem appearances. 

Treatment. — No  real  specific  for  hooping-cough. — Treatment  of  first  and  second  stages 
— utility  of  hydrocyanic  acid — of  counter-irritation — of  attention  to  the  temperature 
— danger  of  over-treating  the  bronchitis  of  hooping-cough. — Treatment  of  third  stage 
of  disease. 

It  is  a  peculiarity  of  the  affection  which  we  are  now  studying,  that 
much  of  the  suffering,  and  almost  all  the  danger  that  attend  it,  are  the 
result,  not  of  the  disorder  itself,  but  of  some  complication  that  super- 
venes during  its  course.  We  have  already  examined  the  two  most  fre- 
quent and  most  formidable  sources  of  danger  to  patients  labouring 
under  hooping-cough,  but  others  remain,  against  which  it  behooves  us 
to  be  no  less  sedulously  on  our  guard. 

Some  days  ago  I  mentioned  to  you  that  a  state  of  extreme  irritability 
of  the  lining  of  the  air-tubes  is  one  of  the  characteristics  of  early  child- 
hood. To  this  are  due  the  attacks  of  catarrh  which  children  often 
experience  while  teething,  and  the  cough  which,  wholly  independent  of 
exposure  to  cold,  comes  on  as  the  result  of  sympathy  with  irritation  in 
some  distant  viscus.  This  high  degree  of  susceptibility,  however,  is 
not  confined  to  the  bronchi,  but  is  possessed  in  the  young  subject  by 
the  whole  tract  of  mucous  membranes:  diarrhoea  often  accompanies 
catarrh,  or  alternates  with  it,  and  in  the  course  of  inflammation  of  the 
lungs  the  patient's  life  is  sometimes  jeopardied,  or  his  death  hastened, 
by  the  supervention  of  an  intractable  looseness  of  the  bowels. 

Diarrhoea,  though  comparatively  seldom  fatal,  is  frequently  a  very 
troublesome  complication  of  hooping-cough,  and  if  it  continue,  it  greatly 
reduces  the  strength  of  a  child,  and  interferes  with  the  employment  of 
some  of  those  means  to  which  otherwise  we  might  have,  recourse.  It 
sometimes  sets  in  with  the  preliminary  catarrh,  and  abates  as  that  sub- 
sides, but  in  other  cases  it  harasses  the  patient  at  intervals  during  the 
whole  course  of  the  affection.  It  is,  however,  when  it  supervenes  in 
the  course  of  an  attack  of  hooping-cough  which  has  already  attained 
considerable  severity,  that  it  should  excite  our  chief  solicitude.  It  does 
not,  indeed,  in  the  majority  of  instances,  betoken  the  supervention  of 
disease  in  the  intestines,  but  is  one  of  the  forms  of  constitutional  dis- 
turbance that  attend  upon  a  congested  state  of  the  brain,  or  it  indicates 
the  advance  of  serious  mischief  in  the  lungs.  I  have,  indeed,  seen 
diarrhoea  become  the  most  prominent  symptom  in  a  case  of  severe 
hooping-cough,  the  bowels  being  for  days  so  irritable,  that  their  action 
was  excited  by  the  slightest  article  of  food  or  drink,  while  the  abdomen 
was  exquisitely  tender;  and  yet,  when  death  at  length  took  place, 


264  COMPLICATIONS   OF   HOOPING-COUGH — DIARRHOZA,  ETC. 

unusual  redness  and  prominence  of  the  Peyerian  glands  were  the  only 
morbid  appearances  in  the  intestines,  while  the  signs  of  intense  bron- 
chitis, and  inflammation,  which  in  some  parts  had  advanced  to  suppu- 
ration, were  discovered  in  the  lungs. 

An  irritable  state  of  the  stomach,  with  occasional  vomiting,  are  symp- 
toms almost  constantly  observed  at  some  period  or  other  in  the  course 
of  hooping-cough.  In  cases  of  a  mild  character,  they  usually  occur 
only  when  the  cough  has  reached  its  acme,  and  vomiting  succeeds  to 
none  but  the  severest  fits  of  coughing,  while  it  is  one  of  the  earliest 
symptoms  to  cease  as  the  severity  of  the  disease  declines.  Sometimes, 
however,  very  distressing  nausea  harasses  the  patient,  and  efforts  to 
vomit  not  only  follow  the  paroxysms  of  coughing,  but  are  excited  by 
food  or  by  the  blandest  fluid.  I  have  already  warned  you  of  the 
serious  import  of  this  symptom  in  many  instances,  and  have  called 
your  attention  to  it  as  being  frequently  one  of  the  earliest  indications 
of  cerebral  mischief.  In  some  few  instances  I  have  observed  it  come 
on  very  early  in  the  disease,  and  subside  by  degrees  as  the  cough 
assumed  a  distinctly  paroxysmal  character;  just  as  is  the  case  some- 
times with  that  nervous  dyspnoea  of  which  I  spoke  in  my  last  lecture. 
Sometimes  it  continues  to  be  a  troublesome  though  almost  a  solitary 
symptom  of  disturbance  of  the  nervous  system,  the  cough  not  being 
severe,  nor  the  child's  health  at  all  seriously  impaired ;  and  in  two 
instances  that  I  met  with  it  appeared  to  be  the  result  of  a  state  of  ex- 
treme irritability  about  the  fauces,  so  that  the  cough,  which  hardly  ever 
occurred  at  other  times,  was  immediately  excited  by  any  attempt  at 
deglutition,  and  the  effort  to  cough  terminated  almost  directly  in  vomit- 
ing. Nausea  and  vomiting  are  sometimes  associated  with  general 
intestinal  disorder  and  diarrhoea ;  at  other  times  there  is  equal  evidence 
of  disorder  of  the  digestive  organs  in  a  constipated  state  of  the  bowels, 
a  red  tongue,  with  perhaps  numerous  small  aphthous  ulcers  about  the 
mouth,  or  in  the  large  quantity  of  frothy  mucus  rejected  by  the  stomach 
at  each  effort  to  vomit. 

Before  leaving  the  subject  of  the  complications  of  hooping-cough,  I 
must  notice  the  relation  that  appears  to  exist  between  it  and  two  of  the 
eruptive  fevers  ;  namely,  measles  and  chicken-pox.  It  has  been  thought, 
indeed,  by  some  writers,  that  there  is  no  connection  between  these 
diseases  other  than  that  of  their  accidental  association ;  but  my  own 
experience  would  lead  me  to  incline  to  an  opposite  opinion,  which  is 
likewise  entertained  by  several  high  authorities.  I  am  not,  indeed,  able 
at  this  moment  to  adduce  a  number  of  observations  bearing  on  this 
point  sufficient  to  establish  the  fact  beyond  doubt ;  but  my  belief  is, 
that  the  occurrence  of  any  one  of  these  diseases  during  the  epidemic 
prevalence  of  another,  increases  the  liability  of  the  child  to  become 
affected  by  that  which  is  epidemic ;  and  that  an  exacerbation  of  the 
fever  of  hooping-cough,  and  the  appearance  of  more  serious  illness  than 
the  local  symptoms  account  for,  is  very  likely  to  be  due  to  the  approach 
either  of  measles  or  varicella.  Like  other  intercurrent  febrile  and  in- 
flammatory affections,  both  measles  and  chicken-pox  often  produce  some 
temporary  abatement  of  the  paroxysms  of  hooping-cough,  and  some- 
times cure  the  disease  altogether.     In  this,  however,  there  is  nothing 


DURATION   OF   HOOPING-COUGH.  265 

constant,  for  hooping-cough  often  appears  not  to  be  in  the  least  modi- 
fied in  its  character  by  the  supervention  of  the  other  malady :  while  in 
some  cases  the  complication  adds  to  the  mischief  in  the  chest,  and 
increases  the  patient's  suffering  and  danger. 

Although  there  are  many  important  points  of  analogy  between 
hooping-cough  and  some  of  the  exanthemata,  yet  in  nothing  is  the 
difference  between  these  affections  more  apparent  than  in  the  uncertain 
duration  of  the  former,  in  the  exacerbations  which  take  place  during  its 
course,  either  causelessly  or  -from  very  slight  occasions,  and  in  the 
actual  relapses  that  sometimes  occur  after  apparent  cure.  It  is  a  matter 
of  considerable  difficulty,  in  the  case  of  a  disease  so  protracted  in  its 
course  as  hooping-cough,  to  make  even  an  approximation  to  a  correct 
estimate  of  its  duration.  In  twenty-five  cases,  however,  I  had  the 
opportunity  of  watching  the  patients  from  the  time  when  the  cough  first 
assumed  a  paroxysmal  character,  or  the  hoop  first  became  audible,  until 
the  final  cessation  of  all  cough.  From  this  small  number  of  observa- 
tions I  should  be  disposed  to  estimate  the  average  duration  of  hooping- 
cough  at  ten  weeks ;  of  whiqh  period  nearly  two  weeks1  would  be  occu- 
pied by  the  preliminary  catarrh,  for  four  weeks  the  cough  would  pre- 
sent the  characteristic  hoop,  and  the  cough  would  continue  for  about 
the  same  period  to  occur  occasionally,  gradually  losing  its  paroxysmal 
character ;  though  exposure  to  cold,  or  any  trivial  cause,  would  suffice 
to  bring  back  the  hoop,  and  to  restore  to  the  paroxysms  of  the  cough 
all  their  former  intensity.  So  long  as  any  cough  continues,  even  though 
very  occasional  in  its  occurrence,  and  though  the  hoop  have  entirely 
ceased  for  many  weeks,  the  patient  cannot  be  regarded  as  well ;  while 
the  neglect  of  proper  hygienic  precautions  may  protract  the  duration 
of  the  cough  for  between  three  and  four  months, — an  occurrence  by  no 
means  unusual  among  the  poor.  I  have  on  several  occasions  treated 
children  for  hooping-cough  during  the  spring,  in  whom  the  hoop  has 
disappeared,  and  the  cough  almost  ceased,  in  the  warm  months  of  sum- 
mer ;  but  on  the  approach  of  autumn  has  returned  with  nearly  its  former 
intensity.  In  other  cases,  hooping-cough  contracted  in  the  early  part 
of  autumn  has  returned  during  the  prevalence  of  cold  March  winds ;  or 
a  casual  catarrhal  seizure  has  been  followed  by  a  recurrence  of  all  the 
signs  of  the  disease  in  a  severe  form.  These  relapses  of  hooping-cough 
frequently  set  in  with  considerable  severity,  the  paroxysms  of  cough 
being  very  frequent,  and  the  hoop  loud  and  often  repeated ;  but,  if 
treated  judiciously,  they  are  much  more  amenable  to  remedies  than  is 
the  first  attack  of  the  disease. 

A  true  recurrence  of  hooping-cough,  after  the  disease  has  been  per- 
fectly cured,  is  at  least  as  unusual  as  the  occurrence  of  measles  or 
small-pox  twice  in  the  same  subject.  Only  one  instance  of  hooping- 
cough  affecting  the  same  patient  more  than  once  has  come  under  my 
notice.     In  that  case  the  patient  was  a  girl  aged  seven  years,  who, 

1  The  estimate  of  the  duration  of  the  catarrhal  stage  is  deduced  from  the  observations 
of  55  cases,  and  the  exact  period  of  its  continuance  was  12-7  days.  Of  the  25  in  which 
the  total  duration  of  the  cough  from  the  occurrence  of  the  tirst  hoop  was  noted,  11,  or 
nearly  half,  showed  a  duration  of  eight  weeks ;  and  the  duration  in  the  remaining  14 
cases  varied  from  four  to  twelve  weeks. 


266  CAUSES   INFLUENCING   ITS   PRODUCTION. 

when  three  years  old,  had  very  severe  hooping-cough,  -which  lasted  for 
several  weeks,  the  paroxysms  of  cough  being  frequent,  and  the  hoop 
loud  and  often  repeated.  In  March  1845,  hooping-cough  being  then 
epidemic,  she  experienced  a  return  of  the  disease  in  a  very  severe  form, 
and  continued  to  suffer  from  it  until  the  end  of  June. 

But  little  more  remains  to  complete  the  history  of  the  disease,  except 
that  we  notice  briefly  the  circumstances  under  which  it  comes  on.  It 
is  essentially  an  affection  of  childhood,  few  children  escaping  from  it, 
while  more  than  half  of  the  cases»of  it  oicur  before  the  completion  of 
the  third  year.  After  the  age  of  five  years  its  frequency  rapidly 
diminishes,  and  after  ten  it  becomes  so  extremely  rare,  that  out  of 
1367  cases  in  which  I  noticed  the  patient's  age,  I  found  but  eleven  in 
which  it  exceeded  ten  years.1  The  occurrence  of  the  disease  appears 
to  be  influenced  to  a  considerable  degree  by  sex  as  well  as  age;  and, 
as  is  the  case  with  a  larger  number  of  the  non-inflammatory  disorders 
of  the  nervous  system,  females  suffer  from  it  in  a  considerably  larger 
proportion  than  males.  Of  100  cases  of  hooping-cough  at  the  Children's 
Infirmary,  55*3  per  cent,  occurred  in  females,  only  44.7  per  cent,  in 
males;  although  the  total  number  of  female  children  to  the  total 
number  of  males  among  my  patients  at  that  institution  was  only  as 
50-2  to  49-8 

Age  and  sex  exert  an  evident  influence  on  the  mortality  of  the 
disease  as  well  as  on  its  prevalence,  both  being  greatest  in  early  child- 
hood, though  hooping-cough  does  not  seem  to  be  so  formidable  before 
the  commencement  of  dentition  as  it  is  while  that  process  is  going  on. 
Female  children  are  not  only  more  liable  to  the  affection,  but  it  proves 
more  fatal  to  them  than  to  boys  in  the  proportion  of  about  3  to  2.2 

Hooping-cough  is  a  disease  of  all  climates,  and  though  more  frequent 
in  the  cold  than  in  the  warm  months  of  the  year,  yet  its  epidemics 

1  Of  the  above  1367  cases — 

41-2  per  cent,  occurred  during  the  first  2  years  of  life. 
i  50-7  «  «  «  3 

82-9  "  "  "  5        " 

98-4  "  "  "  10         " 

The  subjoined  table  shows  the  proportion  borne  by  these  hooping-cough  cases  to 
14.440  cases  of  all  diseases  at  the  same  ages,  which  occurred  during  the  same  period  at 
the  Children's  Infirmary.     Cases  of  hooping-cough  constituted— 

8-4  per  cent,  of  all  cases  occurring  under  the  age  of  6  months. 


10-4 

" 

4t 

ti 

from  6  months  to  12  months. 

10-3 

«« 

«( 

<< 

«   12 

" 

18       « 

9-3 

<< 

a 

<< 

"    18 

u 

2  years. 

122 

M 

«< 

«< 

"     2  years 

to 

3     " 

14-6 

ti 

<( 

<« 

"     3 

<« 

4     " 

13-2 

a 

<« 

<( 

"     4 

ti 

5     " 

11-2 

<< 

«( 

«< 

under 

5     " 

7-2 

it 

<< 

it 

from  5 

<( 

10     »< 

8 

it 

u 

" 

"     10 

u 

15     " 

2  The  subjoined  table  shows  the 

age 

at  which  death  took 

place 

in 

27  fatal  cases  of 

hooping-cough:— 

0  under  6  months. 

4  between  0  months  and  1  year. 
6        "        1  year  and  2  years. 

5  "        2  3       " 
2        "       3         "        4       " 


5  between  4  years  and  5  years. 

1  «       5  G 

2  "  6  "7 
1  "  7  "8 
1         «     10         "      11 


INFLUENCE   OF   VARIOUS   CAUSES   IN   THE   PRODUCTION   OF  267 

break  out  at  almost  all  seasons.  The  epidemic  of  1841-2  reached  its 
acme  in  the  months  of  December  and  January;  while  in  1845,  cases  of 
hooping-cough  were  by  far  more  numerous  in  the  months  of  June  and 
July  than  during  any  other  part  of  the  year.  Though  little  influenced 
by  the  season  of  the  year,  the  outbreak  of  an  epidemic  of  hooping- 
cough  seldom,  if  ever,  takes  place  suddenly,  and  altogether  without 
warning.  Sometimes,  as  already  mentioned,  it  succeeds  to  an  epidemic 
of  measles,  but  still  more  frequently  it  follows  an  unusual  prevalence 
of  catarrh,  which  gradually  assumes  a  paroxysmal  character,  and  puts 
on  the  characters  of  hooping-cough.  In  a  similar  way,  epidemic 
hooping-cough  sometimes  resolves  itself  into  simple  catarrh  ;  the  signs 
of  disturbance  of  the  nervous  system  by  degrees  disappearing,  and  the 
cases  presenting  the  indications  of  mere  bronchial  irritation. 

The  question  whether  hooping-cough  is  a  contagious  disease,  has 
long  since  been  set  at  rest  by  a  general  answer  in  the  affirmative. 
How  long  it  retains  this  character  is  an  inquiry  to  which  it  is  not 
possible  to  return  any  very  precise  reply ;  but  so  long  as  a  child  who 
has  suffered  from  hooping-cough  continues  to  cough  at  all, even  though 
only  once  or  twice  a  day,  I  should  be  unwilling  to  restore  him  to  the 
society  of  children  who  have  not  already  had  the  disease.  All  children 
are  not  equally  susceptible  of  the  contagion,  and  infants  under  six 
months  old  appear  to  be  especially  indisposed  to  receive  it,  either  by 
association  with  other  children,  or  as  the  result  of  atmospheric  influence. 
If  carefully  kept  from  contact  with  other  children,  infants  of  tender 
age  will  very  often  escape  during  the  general  prevalence  of  hooping- 
cough  ;  and  in  nearly  half  of  the  cases  of  hooping-cough  that  I  have 
met  with  in  infants  under  six  months  old,  other  children  in  the  family 
had  suffered  from  it  for  a  week  or  ten  days  before  the  infants  showed 
any  symptoms  of  it. 

You  may  expect,  perhaps,  that  before  I  pass  to  the  consideration  of 
the  treatment  of  hooping-cough,  I  should  say  something  about  the 
morbid  appearances  to  which  it  gives  rise,  and  about  the  essential  nature 
of  the  affection.  I  know,  however,  of  no  morbid  appearances  peculiar 
to  this  disease,  nor  do  I  think  that  much  would  be  gained  by  a  dis- 
quisition on  its  seat,  or  on  the  occult  cause  of  its  symptoms.  It  is 
through  the  medium  of  the  lungs,  or  of  the  brain,  that  death  takes 
place  in  nearly  every  instance  of  fatal  hooping-cough  ;  and  almost  all 
the  structural  lesions  of  importance  are  found  in  one  or  other  of  those 
organs.  The  vessels  of  the  brain  and  its  membranes  are  often  found 
over-filled  with  blood,   though  even  in  cases  where  death  has  taken 

This  result  tallies  very  closely  with  that  afforded  by  the  Fifth  Report  of  the  Registrar- 
Geueral,  from  which  it  appears,  that  the  deaths  from  hooping-cough  in  London  were 
to  the  deaths  from  all  causes  in  the  proportion  of — 

5-0  per  cent,  between  5  and  10  years. 
8         "  "         10    "    15      " 


5-6  per  cent,  under  1  year  old. 
10-6         "         between  1  and  3  years. 
10-2         "  "         3    »    5      » 


Of  the  27  cases  that  came  under  my  notice,  16  occurred  in  female,  and  only  11  in 
male  children,  and  the  mortality  under  ten  years  of  age  from  hooping-cough  is  to  the 
total  mortality  at  that  age  in  Loudon  in  the  proportion  of  8-9  per  cent,  among  female, 
and  6-1  per  cent,  among  male  children. 


268  HOOPING-COUGH — MORBID  APPEARANCES. 

place  in  convulsions,  or  has  been  preceded  by  a  comatose  condition, 
these  appearances  are  sometimes  much  less  marked  than  might  have 
been  expected,  and  occasionally  are  altogether  absent.  Softening  of 
the  cerebral  substance,  or  other  indications  of  inflammatory  action,  are 
very  seldom  met  with  ;  increased  vascularity  of  the  organ,  with  perhaps 
a  small  quantity  of  fluid  in  the  ventricles,  being  almost  the  only  morbid 
appearances  in  the  encephalon. 

It  is  but  seldom  that  the  lungs  are  found  free  from  disease,  though 
they  present  no  structural  changes  that  can  be  regarded  as  charac- 
teristic of  hooping-cough.  The  mucous  membrane  of  the  bronchi  is 
generally  injected  ;  sometimes  it  is  intensely  red,  while  an  abundant  secre- 
tion of  thick  mucus  occupies  the  cavities  of  the  air-tubes,  and  their  calibre 
is  much  increased.  This  dilatation  of  the  bronchi,  which  sometimes  is 
very  remarkable,  arises  from  inflammation  of  the  air-tubes,  just  as  it 
does  in  ordinary  bronchitis,  and  is  not  due,  as  has  been  erroneously 
supposed  to  the  violence  of  the  child's  inspiratory  efforts.  The  emphy- 
sematous condition  of  the  lung,  which  is  likewise  observed  in  some 
cases  of  fatal  hooping-cough,  has  been  referred  to  the  same  forcible 
attempts  at  inspiration.  MM.  Rilliet  and  Barthez,1  however,  have 
observed,  with  great  justice,  that  the  supposed  violence  of  the  inspi- 
ratory efforts  during  hooping-cough,  is  altogether  a  mistaken  assumption ; 
for  the  efforts  made  during  the  paroxysm  of  coughing  are  expiratory, 
the  lungs  during  a  severe  seizure  being  almost  emptied  of  air ;  while  in 
the  inspiratory  efforts  that  succeed,  the  air  at  first  does  not  penetrate 
beyond  the  larger  bronchi,  and  is  long  before  it  again  freely  permeates 
the  pulmonary  vesicles.  My  own  experience  fully  confirms  the 
statement  of  these  gentlemen,  that  emphysema  is  found  only  in  those 
cases  cf  hooping-cough  in  wThich  it  has  been  complicated  with  bronchitis 
or  pneumonia,  or,  I  may  add,  with  extensive  collapse  of  the  lung ;  so 
that  it  is  to  these  secondary  affections  rather  than  to  the  hooping-cough 
itself  that  the  dilatation  of  the  pulmonary  vesicles  is  to  be  attributed  ; 
and  the  amount  of  emphysema  will  be  usually  found  proportionate  to 
the  extent  of  those  other  lesions,  and  the  rapidity  with  which  they 
supervene.  But,  although  the  direct  tendency  of  the  paroxysms  of 
hooping-cough  is  to  prevent  rather  than  to  induce  emphysema,  the 
forcible  expiratory  efforts  which  characterize  them  favour  the  occurrence 
of  that  collapse  of  the  lung  to  which  on  a  former  occasion  I  directed 
your  attention  ;  and  few  cases  of  hooping-cough  terminate  fatally  in 
which  you  will  not  find  after  death  a  more  or  less  considerable  portion 
of  lung  in  this  condition.  It  may  be  simply  collapsed,  resuming, 
its  natural  appearance  readily  when  inflated,  or  the  bronchial  tubes 
may  have  been  the  seat  of  inflammation,  and  be  more  or  less  filled  with 
puriform  mucus,  when  the  characters  of  vesicular  bronchitis  will  be 
superadded  to  those  of  mere  collapse  or  carnification,  and  air  will 
permeate  the  organ  very  imperfectly,  or  not  at  all.  It  cannot  be 
necessary  to  describe  again  those  other  changes  which  may  take  place 
in  carnified  lung,  and  which  end  in  the  infiltration  of  pus  into  its  tissue, 

i  Lib.  cit.  vol.  ii.  p.  217. 


CONDITION   OF   THE   PNEUMOGASTRIC   NERVES.  269 

or  in  the  formation  of  vomicae,  since  I  treated  fully  of  this  subject  a 
few  days  ago.1 

I  do  not  dwell  on  other  appearances  in  the  chest,  such  as  pleurisy 
and  lobar  pneumonia,  which  are  much  less  often  met  with,  and  which 
have  none  other  than  a  perfectly  casual  connection  with  hooping-cough ; 
but  I  must  notice  one  morbid  condition  alleged  to  have  been  frequently 
observed,  and  which  is  of  the  more  importance,  since  it  has  served  as 
the  foundation  of  a  theory  of  the  disease.  The  pneumogastric  nerve 
has  been  discovered  by  various  observers  redder  than  natural,  and  in 
some-cases  swollen  and  softened — appearances  which  have  been  regarded 
as  indicating  that  it  had  been  the  seat  of  inflammation.  Even  those 
observers,  however,  who  have  noticed  this  condition,  appear  to  have 
met  with  it  but  seldom,  while  others  have  sought  for  it  in  vain  in  a 
large  number  of  cases.  Professor  Albers  of  Bonn,2  states,  that,  having 
examined  the  bodies  of  47  children  who  died  of  hooping-cough,  he 
found  the  nervi  vagi  perfectly  healthy  in  43.  In  3  the  vagus  of  the 
right  side,  and  in  1  that  of  the  left  side,  were  slightly  reddened  ;  but 
this  redness  corresponded  to  the  side  towards  which  the  body  had  been 
inclined,  and  in  no  respect  differed  from  what  is  observed  in  the  bodies 
of  plethoric  persons,  and  of  patients  who  have  died  of  typhus  fever. 
Out  of  18  examinations  of  the  bodies  of  children  who  have  died  of 
hooping-cough,  it  has  only  once  happened  to  me  to  observe  any  altera- 
tion in  the  appearance  of  the  vagus,  though  my  attention  has  been 
directed  to  it  on  every  occasion.  In  this  instance  both  nerves  seemed 
to  be  of  a  decidedly  redder  colour  than  natural,  although  they  were  not 
otherwise  altered.  We  are,  I  think,  warranted  in  concluding  that  an 
appearance  so  frequently  absent,  cannot  be  one  of  much  moment,  that 
it  is  probably  a  post-mortem  alteration,  and  that  certainly  it  is  not  a 
phenomenon  which  can  be  adduced  in  support  of  any  particular  hypo- 
thesis as  to  the  nature  of  the  affection. 

1  It  -would  be  unjust  to  leave  this  subject  -without  calling  the  reader's  attention  to  the 
excellent  account  of  collapse  or  carnification  of  the  lung  contained  in  Dr.  Alderson's 
paper  on  the  Pathology  of  Hooping-cough,  published  in  the  year  1830,  in  vol.  xvi.  of  the 
Medico-Chirurgical  Transactions.  In  this  paper  he  not  only  describes  very  correctly 
the  anatomical  characters  of  this  condition,  which  had  merely  been  indicated  by 
previous  observers,  and  speaks  of  it  as  a  state  different  from  pneumonia,  which  MM; 
llufz  and  Gerhard  did  four  years  later,  but  he  also  suggests  an  explanation  of  its  occur- 
rence, which  the  recent  researches  of  MM.  Bailly  and  Legendre  prove  not  to  have  been 
far  from  the  truth. 

It  may  be  well  to  quote  two  passages  from  this  paper: — "In  many  other  [cases]  I 
have  invariably  found  the  same  appearances,  uncomplicated  with  any  evidence  of 
pleuritic  inflammation.  In  the  lower  and  posterior  portions  of  the  lungs,  the  structure 
was  rendered  very  firm  and  dense:  the  portions  which  were  the  subject  of  this  change 
exactly  defined  by  the  septa;  of  a  dull-red  colour,  devoid  of  air,  sinking  instantly  in 
water,  and  thin  slices  undergoing  no  change  by  ablution.  The  individual  lobules  were 
more  dense  than  in  hepatized  lungs  ;  and  the  cellular  membrane  between  them,  retaining 
its  natural  structure,  conveyed  to  the  touch  the  same  sensation  that  is  felt  on  touching 

the  pancreas I  apprehend  that  the  appearances  detailed  differ  from  those  found  in 

peripneumony.  In  hooping-cough,  the  lung  is  always  dense  and  contracted,  as  if  the 
air  had  been  expelled,  and  from  the  throwing  out  of  adhesive  matter,  the  sides  of  the 
air-sells  had  been  agglutinated  together;  while  in  hepatization,  the  lung  is  less  dense 
than  in  hooping-cough,  and  is  rendered  more  voluminous  than  in  its  natural  state." 
(pp.  90-91). 

*  Quoted  by  Aberle,  De  Tussi  Convulsiva,  8vo.  p.  45.     Vindobonse,  1843. 


270  TREATMENT  OF  THE  FIRST  STAGE  OF  HOOPING-COUGH. 

I  have  endeavoured  to  describe  to  you  the  symptoms  of  this  affection, 
to  make  you  acquainted  with  the  circumstances  under  which  it  occurs, 
with  the  course  that  it  usually  follows,  and  with  the  chief  dangers  that 
threaten  a  child  while  suffering  from  it.  It  now  remains  to  examine 
the  treatment  which  may  be  best  calculated  to  mitigate  its  severity, 
and  to  ward  off  or  overcome  the  dangers  that  attend  it. 

There  are  few  diseases  for  the  cure  of  which  specifics  have  been  more 
eagerly  sought  after,  or  more  earnestly  recommended,  than  for  that  of 
hooping-cough  ;  neither  is  there  anything  unreasonable  in  the  expecta- 
tion that  a  remedy  may  some  day  or  other  be  discovered  which  shall 
cut  short  its  course  with  as  much  certainty  as  quinine  arrests  an  inter- 
mittent fever,  or  which  shall  render  the  constitution  insusceptible  of 
its  poison  as  infallibly  as  chicken-pox  preserves  from  variola.  At 
present,  however,  no  such  remedy  has  been  discovered ;  and,  though 
the  severity  of  an  attack  of  hooping-cough,  or  its  duration,  varies 
greatly  in  different  individuals,  during  different  epidemics,  or  at  different 
seasons  of  the  year,  yet  we  are  unable  by  any  medicinal  agents  to 
produce  effects  such  as  in  these  cases  flow  from  causes  quite  beyond 
our  control. 

For  the  present,  then,  the  treatment  of  hooping-cough  must  be  con- 
ducted in  accordance  with  the  ordinary  principles  of  therapeutics,  and 
we  shall  study  their  application  best  by  examining  in  succession  the 
course  which,  in  each  stage  of  the  disease,  it  will  be  our  duty  to  pursue. 
The  first  stage  of  hooping-cough  is  distinguished,  as  you  know,  by 
catarrhal  symptoms,  with  some  degree  of  febrile  disturbance,  and  a 
cough,  which  gradually  assumes  more  and  more  of  a  paroxysmal 
character,  until  at  length  it  returns  in  well-marked  fits,  and  is  attended 
by  a  distinct  hoop.  In  the  majority  of  cases  the  treatment  of  this  first 
stage  of  hooping-cough  must  be  just  that  of  an  ordinary  catarrh.  The 
child  must  remain  in  the  house,  and  it  is  desirable  that  it  should  be 
confined  to  its  own  apartments,  both  of  which  should  be  maintained  at 
a  temperature  of  60°,  so  that  when  it  leaves  the  day  for  the  night 
nursery,  it  may  not,  as  is  too  commonly  the  case,  enter  a  colder 
atmosphere,  and  thus  have  the  irritability  of  the  bronchi  increased, 
and  the  severity  of  the  cough  aggravated.  If  these  precautions  be 
carefully  observed,  and  the  diet  be  light  and  unstimulating,  but  little 
medicine  is  needed,  beyond  what  may  be  required  to  keep  the  bowels 
regularly  open.  If  the  cough  be  at  all  troublesome,  a  mixture  may  be 
given,  containing  small  doses  of  the  Vinum  Ipecacuanha  and  solution 
of  tartar  emetic,  with  a  few  drops  of  laudanum,  or  of  the  compound 
tincture  of  camphor,1 — medicines  that  I  should  advise  you  always  to 
use  in  preference  to  the  syrup  of  poppies,  the  strength  of  which  is  very 
variable,  and  its  action  uncertain.  If,  as  is  sometimes  the  case,  the 
child  should  wheeze  a  good  deal,  this  symptom  will  be  much  relieved 
by  the  administration  of  an  emetic  of  ipecacuanha  every  evening,  or 
more  frequently  if  necessary.  It  is  not  always,  indeed,  that  either 
much  care  or  much  medicine  is  needed ;  and  if  hooping-cough  come  on 
in  a  perfectly  healthy  child,  in  whom  the  process  of  dentition  is  coin- 

1  See  Formula,  No.  9,  p.  171. 


OF   ITS    SECOND  STAGE.  271 

pleted,  and  during  the  warm  months  of  summer,  strict  confinement  to 
the  house  may  not  be  necessary.  Usually,  however,  care  in  this  stage 
is  very  important,  and  will  do  much  towards  mitigating  the  severity  of 
the  subsequent  course  of  the  disease,  while  no  precautionary  measure  is 
of  so  much  moment  as  the  preservation  of  the  child  from  fluctuations  of 
temperature,  and  from  damp  as  well  as  cold. 

When  the  first  stage  of  hooping-cough  has  passed  into  the  second,  in 
which  the  disease  assumes  its  characteristic  features,  the  condition  of 
the  patient  must  still  determine  whether  any  remedies  are  to  be 
employed,  and  must  likewise  influence  their  selection.  It  sometimes 
happens  that  the  cough  and  hoop  are  very  slight,  and  the  paroxysms 
but  few  in  the  course  of  the  day ;  and,  under  such  circumstances, 
medicine  can  well  be  dispensed  with.  If  the  paroxysmal  character  of 
the  cough  be  well  marked,  and  the  fits  of  frequent  occurrence,  but  the 
child  in  other  respects  ails  little,  much  benefit  will  accrue  from  the  use 
of  the  hydrocyanic  acid.  I  usually  begin  with  a  dose  of  half  a  minim 
of  the  acid  of  the  London  Pharmacopoeia  every  six  hours  for  a  child 
nine  months  old ;  gradually  increasing  the  dose  to  one  minim  every 
four  hours,  for  a  child  of  that  age,  and  so  on  in  proportion  for  older 
children.1     This  remedy  sometimes  exerts  an  almost  magical  influence 

(No.  14.)  (No.  15.) 

1  $  Acid.  Hydrocy.  dil.  rr^iv.  R  Acid.  Hydrocy.  dil.  TT^iv. 

Sodse  Sesquicarb.  gr.  x.  Sodoe  Sesquicarb.  gr.  x. 

Syrupi  simplicis,  gj.  Mist.  Amygdalae,  ^j.     M.     gj.  6tis 

Aquas  destill.  gvij.     M.     gj.  6tis  horis. 
horis. 

For  a  child  9  months  old. 

on  the  cough,  diminishing  the  frequency  and  severity  of  its  paroxysms 
almost  immediately  ;  while  in  other  cases  it  seems  perfectly  inert;  and 
again,  in  others,  without  at  all  diminishing  the  severity  of  the  cough, 
it  exerts  its  peculiar  poisonous  action  on  the  system,  so  as  to  render  its 
discontinuance  advisable.  I  have  never  but  once,  however,  seen  really 
alarming  symptoms  follow  its  use,  though  I  have  employed  it  in  many 
hundreds  of  cases.  In  that  instance  I  gave  one  minim  of  hydrocyanic 
acid  every  four  hours  to  a  little  boy  two  years  and  a  half  old.  Be  had 
hooped  for  four  days  before  he  came  under  my  care,  and  was  then 
suffering  from  rather  severe  cough,  and  considerable  dyspnoea.  He 
took  the  acid  for  four  days  without  any  effect  being  produced  either  on 
his  system  generally  or  on  the  cough ;  but  at  the  end  of  that  time,  after 
taking  each  dose,  he  uttered  a  cry,  became  quite  faint,  and  would  have 
fallen  if  not  supported.  This  result  having  followed  three  or  four 
times,  the  child's  mother  discontinued  the  medicine,  and,  of  course,  I 
did  not  resume  its  employment.  Similar,  though  less  severe  symptoms 
were  produced  by  the  same  medicine  in  the  sister  of  this  child,  a  little 
girl  of  five  years  of  age ;  but  in  neither  instance  was  the  severity  of  the 
cough  in  the  least  mitigated  by  it.  Though  no  other  instances  of  the 
kind  have  come  under  my  notice,  I  always  give  a  caution  to  the  parents 
to  diminish  the  dose  of  the  medicine,  or  even  entirely  to  discontinue  it, 


272  TREATMENT   OF   THE    SECOND    STAGE   OF   HOOPING-COUGH. 

if  the  child  appear  faint  or  dizzy,  or  bewildered,  after  its  administration  ; 
and  I  never  persevere  with  the  use  of  the  acid  if  it  do  not  give  a  very 
decided  earnest  of  good  within  three  or  four  days  after  its  first 
exhibition. 

In  many  instances,  although  the  severity  of  the  cough  maybe  greatly 
relieved  by  the  hydrocyanic  acid,  it  yet  does  not  enable  us  entirely  to 
dispense  with  all  other  remedies.  If  there  be  much  wheezing  at  the 
chest,  an  emetic  of -ipecacuanha  should  be  given  once  or  twice  a  day,  in 
order  to  free  the  air-passages  from  the  mucus  which  collects  in  them, 
often  in  very  considerable  quantity,  and  thus  tends,  by  the  obstruction 
it  offers  to  the  free  admission  of  air,  to  favour  the  occurrence  of  collapse 
of  the  lung.  The  degree  to  which  the  child  suffers  from  the  accumula- 
tion of  phlegm  in  the  bronchi  must  determine  whether  the  emetic  be 
given  once. or  oftener  during  the  day.  If  it  be  given  but  once,  the 
evening  should  be  the  time  selected  for  its  administration ;  and,  after 
the  air-tubes  have  been  thus  relieved,  the  child  will  often  rest  well, 
instead  of  passing,  as  it  otherwise  would  do,  a  restless  night,  disturbed 
by  dyspnoea  and  frequent  fits  of  coughing.  In  other  instances  the 
cough  is  unattended  by  much  secretion,  the  child  scarcely  wheezes  at 
all,  and,  even  after  a  severe  paroxysm,  rarely  vomits,  and  never  rejects 
more  than  a  small  quantity  of  phlegm ;  but  when  night  comes  on,  the 
cough  grows  very  distressing  by  its  frequent  return,  even  more  than 
by  the  severity  of  the  paroxysms.  When  this  is  the  case,  a  small  dose 
of  Dover's  powder,  or  of  Dover's  powder  and  the  extract  of  hemlock,1 

(No.  16.) 

1  R  Pulv.  Ipecac,  co.  gr.  ss. 

Pulv.  Extracti  Conii,  gr.  j. 
Pulv.  Cinnamomi,  gr.  ij. 

Sacchari  albi,  gr.  iv.     M.     Ft,  pulvis  hora  somni  capiendus. 
For  a  child  of  two  years  old. 

often  seems  to  soothe  this  irritability  of  the  air-tubes,  and  diminishes  the 
frequency  of  the  cough.  If  there  be  a  good  deal  of  febrile  disturbance,  if 
the  cough  be  hard  as  well  as  violent,  if  it  seem  to  occasion  pain,  and  be 
unattended  with  expectoration,  while,  in  the  intervals  of  the  paroxysms, 
a  frequent,  short,  hacking,  cough  distresses  the  child,  and  generally 
diffused  rhonchus  is  heard  throughout  the  lungs,  the  hydrocyanic  acid 
may  be  advantageously  combined  with  small  doses  of  tartar  emetic  or 
of  the  Yinum  Ipecacuanha.  In  other  cases,  if  the  existence  of 
drowsiness,  with  a  flushed  face,  becoming  livid  during  the  fit  of  cough- 
ing, and  the  suppression  of  the  previously  distinct  hoop,  betoken  the 
presence  of  cerebral  congestion,  the  application  of  a  few  leeches  to  the 
head  will  not  only  greatly  relieve  these  symptoms,  but  will  also  diminish 
both  the  frequency  and  severity  of  the  cough,  and  prepare  the  way  for 
the  more  effective  employment  of  the  hydrocyanic  acid. 

Counter-irritation  to  the  chest  and  spine  is  a  popular  remedy  for 
hooping-cough,  in  which  many  non-professional  persons  place  great 
confidence,  while  they  employ  it  through  all  the  stages  of  the  disease. 
I  do  not  think  that  you  will  in  general  gain  much  by  the  employment 


USE   OP   NARCOTICS   AND   COUNTER-IRRITATION.  273 

of  counter-irritation  until  the  disease  has  begun  to  decline,  though  it  is 
then  often  of  much  service.  There  are,  however,  some  circumstances 
under  which  counter-irritation  may  be  advantageously  resorted  to,  even 
before  the  affection  has  attained  its  greatest  degree  of  severity.  The 
attacks  of  dyspnoea  which  sometimes  occur  during  the  increase  of  the 
disease,  are  often  much  relieved  by  a  mustard-poultice  to  the  chest; 
and  if,  as  occasionally  happens,  these  attacks  return,  though  with  vary- 
ing severity,  almost  every  night  for  several  nights  together,  the  appli- 
cation of  a  mustard  poultice  to  the  chest,  and  the  immersion  of  the 
lower  part  of  the  body  in  a  hot  bath,  on  three  or  four  successive  even- 
ings, may  be  of  service.  In  cases  of  this  kind,  too,  the  daily  friction 
of  the  chest  and  spine  with  an  embrocation  of  soap  liniment  and  the 
Tinctura  Lyttse,  so  as  to  keep  up  a  slight  degree  of  redness  of  the 
surface,  is  often  beneficial ;  or  that  popular  remedy,  Roche's  embroca- 
tion, may  be  used,  if  the  parents  of  the  child  fancy,  as  they  often  do, 
that  it  is  possessed  of  some  specific  virtue. 

As  a  general  rule,  blisters  to  the  chest  are  not  desirable  remedies  in 
young  children ;  but  if  the  cough  should  be  frequent,  hard,  and  painful, 
or  if,  in  connection  with  the  evidences  of  congestion  of  the  brain,  the 
cough  be  suffocative  and  the  hoop  suppressed,  much  good  often  results 
from  their  application.  They  must  not,  however,  be  allowed  to  remain 
above  four  or  six  hours  upon  the  skin ;  neither  is  it  desirable  to  attempt 
to  keep  them  discharging,  on  account  of  the  very  troublesome  sores 
which  they  sometimes  produce.  For  the  same  reason,  too,  I  do  not 
advise  you  to  employ  inunction  of  the  tartar  emetic  ointment,  although 
this  proceeding  was  once  highly  recommended,  and  very  generally 
adopted,  as  a  remedy  for  hooping-cough. 

Attention  to  maintain  a  warm  and  equable  temperature  around  the 
child,  to  prevent  the  stomach  becoming  disordered  by  unsuitable  food, 
and  to  avoid  constipation,  will  in  many  instances  suffice  to  conduct  a 
child  in  safety  through  the  second  stage  of  hooping-cough.  If  the 
severity  of  the  cough,  or  the  condition  of  the  child  in  other  respects, 
seem  to  call  for  more  decided  interference,  your  motto  in  the  selection 
and  employment  of  remedies  must  be,  une  quid  nimis ;"  and  especially 
must  this  be  your  guide  in  the  management  of  those  complications 
which  often  render  hooping-cough  so  dangerous  a  disease. 

In  no  case  is  it  of  more  importance  to  bear  in  mind  this  caution  as 
to  the  danger  of  over-treating  a  patient  who  suffers  from  hooping- 
cough,  than  when,  at  the  commencement  of  the  second  stage  of  the 
disease,  a  sudden  increase  of  fever,  and  the  supervention  of  a  state  of 
permanent  dyspnoea,  seem  to  announce  to  you  that  active  inflammation 
has  attacked  the  lungs  or  air-tubes.  It  is  quite  possible  that  such  may 
be  the  import  of  the  symptoms,  but  it  is  at  least  as  likely  that  they 
result  from  disturbance  of  the  nervous  system.  In  such  a  case,  then,  I 
would  advise  you  to  allow  nothing  but  the  positive  evidence  of  ausculta- 
tion to  lead  you  to  resort  to  free  depletion  and  the  use  of  large  doses  of 
tartar  emetic, — remedies  to  which  you  might  feel  disposed  at  once  to 
have  recourse.  If  you  feel  in  doubt,  remain  for  some  time  with  the 
child,  watch  it  carefully,  auscultate  it  more  than  once  during  your  visit, 

'         18 


274  DANGER    OF   OVER-TREATING   HOOPING-COUGH. 

and  repeat  your  visit  every  two  or  three  hours,1  rather  than  resort  at 
once  to  measures  which,  powerful  either  for  evil  or  for  good,  may,  if 
unwisely  employed,  destroy  the  life  they  were  intended  to  save. 

Example  teaches  louder  than  precept,  and  you  may  learn  a  useful 
practical  lesson  from  the  following  history : — 

A  little  boy,  about  two  years  old,  had  had  slight  catarrh  for  a  fort- 
night, and  towards  the  end  of  this  time  it  was  thought  he  had  hooped 
once  or  twice,  though  very  slightly.  He  ailed  but  little,  and  had  had 
none  other  than  domestic  remedies  during  this  period ;  but  one  night, 
without  any  apparent  cause,  he  became  very  feverish,  his  cough  grew 
worse,  and  his  respiration  very  hurried.  On  this  account  he  was 
depleted  very  freely  by  leeches,  and  calomel  and  antimony  were  given 
in  large  doses  for  two  days,  though  without  any  considerable  diminution 
of  the  dyspnoea.  When  this  treatment  was  first  adopted,  it  was  thought 
that  air  entered  one  lung  but  scantily ;  but  on  the  evening  of  the 
second  day  both  lungs  admitted  air  equally  well,  although  a  good  deal 
of  mucous  rale  attended  the  respiration.  On  the  morning  of  the  third 
day,  the  child's  face  was  flushed,  and  looked  much  oppressed ;  his  lips 
were  rather  livid,  his  respiration  was  extremely  hurried  and  irregular ; 
he  coughed  little,  but  his  cough  had  a  suffocative  character,  and  was 
not  attended  by  a  distinct  hoop.  The  hurried  respiration  was  supposed 
to  indicate  the  continuance  of  graver  mischief  in  the  lungs  than  was 
apparent  on  auscultation,  and  antimony  was  accordingly  given  in  emetic 
doses.  It  did  not  produce  much  sickness,  and  the  respiration  diminished 
but  little  in  frequency  during  its  employment.  On  the  fourth  day  the 
child  still  breathed  very  hurriedly,  and  its  inspirations  varied  from  40 
to  60  in  a  minute,  without  there  being  any  obvious  cause  for  these  great 
changes  in  its  frequency.  On  the  fifth  day  the  breathing  increased  in 
rapidity,  while  the  pulse  began  to  lose  power  ;  and  not  only  had  the 
antimony  ceased  to  exert  any  emetic  action,  but  squills  and  ipecacuanha 
failed  to  induce  vomiting.  Active  measures  were  suspended  towards 
the  evening  of  this  day,  and  a  grain  of  Dover's  powder,  given  every  six 
hours,  somewhat  diminished  the  hurry  of  the  breathing  ;  but  it  was 
discontinued  after  the  third  dose,  on  account  of  the  gradually  deepening 
drowsiness  of  the  child.  The  child,  however,  still  continued  heavy  and 
oppressed,  the  cough  became  more  frequent  and  more  suffocative,  the 
breathing  more  rapid  and  more  irregular.  On  the  morning  of  the 
seventh  day,  a  fit  of  coughing  terminated  in  convulsions ;  and  from 
that  time  until  the  morning  of  the  eighth  day,  when  the  child  died, 
they  were  extremely  violent,  frequent  in  their  return,  followed  by 
carpopedal  contractions,  which  did  not  subside  in  the  intervals  between 
them  ;  while  after  each  convulsion  the  respiration  became  most  distress- 
ingly hurried  and  irregular.  After  a  time  the  breathing  grew  con- 
stantly laboured,  the  face  became  of  a  deep  livid  colour,  the  hands 

I  cannot  refrain  from  directing  the  attention  of  junior  practitioners  to  the  anecdote 
which  Dr.  Cheyne  relates  (at  page  xvii.  of  the  Introduction  to  his  work  on  Hydro- 
cephalus), of  the  very  different  results  that  follow  the  practice  of  two  Army  surgeons, 
one  of  whom  visited  his  patients,  during  the  prevalence  of  an  epidemic  disease,  twice, 
the  other,  four  or  five  times  daily.  The  moral  which  Dr.  Cheyne  .drew  from  the  tale, 
though  obvious  enough,  is  not  sufficiently  borne  in  mind  by  many  who  undertake  the 
treatment  of  children's  diseases. 


ILLUSTRATIVE   CASES.  275 

were  clenched,  and  the  wrists  bent  upon  the  fore-arm ;  the  spine  was 
drawn  slightly  backwards,  and  sensation  was  quite  abolished.  At 
length  a  slight  convulsive  movement  passed  across'  the  face,  and  the 
limbs  relaxed  in  death.  Permission  was  not  obtained  to  make  a  post- 
mortem examination. 

Other  cases  have  come  under  my  notice,  in  some  of  which  I  fell  into 
the  error  against  which  I  have  just  tried  to  warn  you :  in  some  I  saw* 
the  patient  too  late  to  rectify  the  mistake  which  others  had  committed, 
while  in  some  the  right  course  of  treatment  adopted  from  the  first  was 
followed  by  success.  In  a  case  such  as  I  have  related,  the  want  of 
correspondence  between  the  general  symptoms  and  the  auscultatory 
signs  should  have  deterred  from  the  copious  depletion  and  the  free  use 
cf  calomel  and  antimony  in  the  first  instance,  while  it  still  further  con- 
tra-indicated the  employment  of  antimony  in  emetic  doses  subsequently. 
Two  or  three  leeches  to  the  head,  when  the  serious  symptoms  first  came 
on,  would  probably  have  relieved  the  congested  brain ;  the  tepid  bath 
would  have  soothed  the  irritability  and  diminished  the  fever;  and  hydro- 
cyanic acid  would,  most  likely,  have  been  of  service  in  quieting  the 
hurried  breathing.  If  much  febrile  disturbance  had  still  continued, 
small  doses  of  ipecacuanha,  antimony,  and  hyoscyamus,  might  have 
been  tried,  the  antimonial  not  being  given  in  such  doses  as  to  exert  any 
very  considerable  depressing  influence  on  the  system.  A  stimulating 
liniment  to  the  chest  and  spine  should  have  been  used  several  times  in 
the  course  of  the  day,  and  any  sudden  access  of  the  hurried  breathing 
should  have  been  met  by  the  application  of  a  mustard-poultice  to  the 
chest. 

The  difficulties  of  diagnosis  are  sometimes  rendered  smaller,  and  the 
right  course  of  treatment  more  obvious,  by  the  occurrence  of  occasional 
carpopedal  contractions,  or  of  momentary  strabismus  from  the  very 
commencement  of  this  nervous  dyspnoea ;  or  in  other  cases  by  the  absence 
of  any  auscultatory  signs  of  mischief  in  the  chest,  such  as  could  for  a 
moment  lead  you  to  refer  the  hurried  breathing  to  disease  going  on  in 
the  lungs. 

Even  when  acute  bronchitis  really  exists,  you  must  not  forget  the 
peculiar  impress  which  hooping-cough  stamps  upon  it.  You  must  bear 
in  mind  the  impediment  to  the  due  aeration  of  the  blood  which  each  fit 
of  coughing  occasions,  and  the  influence  on  the  nervous  system  gene- 
rally of  the  imperfect  decarbonization  of  the  circulating  fluid ;  how  it 
heightens  the  irritability  of  the  spinal  system,  thus  exciting  the  hurried 
and  irregular  breathing,  and  rendering  the  child  peculiarly  liable  to 
convulsive  seizures.  If  active  interference,  therefore,  be  necessary,  you 
would  abstract  blood  very  cautiously,  while  you  would  employ  nitre, 
ipecacuanha,  and  James's  powder  in  small  doses,  as  a  febrifuge  and 
expectorant,  rather  than  attempt  to  bring  the  child  rapidly  under 
the  influence  of  antimony.  At  the  same  time,  the  peculiar  tendency  to 
obstruction  of  the  air-tubes,  and  consequent  collapse  of  the  lungs,  which 
characterizes  hooping-cough,  would  lead  you  to  endeavour  to  keep  the 
bronchi  free,  by  the  administration  once  or  twice  a  day  of  an  emetic  of 
ipecacuanha.     You  would  employ  liniments,  mustard-poultices,  or  blis- 


276     TREATMENT  OF  THE  NERVOUS  SYMPTOMS  OE  BRONCHITIS. 

ters  to  the  chest,  to  combat  any  exacerbation  of  dyspnoea ;  and  if  the 
paroxysms  of  cough  be  severe,  you  would  combine  hydrocyanic  acid 
with  your  other  remedies.  If  the  powers  appeared  to  be  on  the  decline, 
and  the  child  neither  expectorate  with  the  cough,  nor  reject  much  phlegm 
by  vomiting,  although  the  bronchi  are  loaded  with  mucus,  you  would  at 
once  discontinue  antiphlogistic  measures,  and  have  recourse  to  the 
decoction  of  senega,  with  ammonia  and  squills,1  while  you  endeavoured 
by  a  nutritious  diet  to  support  your  patient's  strength. 

The  time  allotted  to  this  lecture  will  not  enable  me  to  do  more  than 
just  indicate  the  main  points  to  which  your  attention  should  be  directed  ; 
and  I  must  now  pass  on  to  notice  briefly  your  conduct  in  the  third  stage 
of  the  disease.  It  is  now  that  the  cough  diminishes  in  frequency  and 
severity,  that  the  hoop  grows  less  loud  and  less  constant,  and  that  any 
signs  of  constitutional  disturbance  that  had  existed  before  by  degrees 
disappear.  When  the  disorder  runs  this  favourable  course  no  medicine 
is  needed,  and  but  few  restrictions,  beyond  such  as  the  avoidance  of 
damp  and  cold  requires.  Change  of  air  generally  expedites  the  cure; 
and  if  the  opportunity  offer,  and  the  season  of  the  year  be  favourable, 
it  should  never  be  neglected.  There  are  many  instances,  however,  in 
which  medical  treatment  in  the  decline  of  hooping-cough  is  of  very  con- 
siderable service.  It  sometimes  happens  that  the  bronchi  continue  loaded 
with  secretion,  which  is  either  expectorated,  or  rejected  by  vomiting  in 
very  considerable  quantities  after  each  fit  of  coughing,  while  the  skin 
is  cold,  the  tongue  moist,  and  the  pulse  soft  and  rather  deficient  in 
power.     In  this  condition,  alum,2  long  a  popular  remedy  in  hooping- 

(No.  17.) 

2  R  Alum.  Sulphat.  gr.  xxiv. 
Acid.  Sulph.  dil.  lr^xy. 
Syr.  Rhoeados,  giv. 
Aquoe  purse,  ^iiss.     M.     giij.  6tis  horis. 

cough,  is  often  of  much  service,  diminishing  the  secretion,  arresting  the 
sickness,  and  rendering  the  cough  much  less  frequent.  It  may  be  given 
in  doses  of  three  or  four  grains  every  four  or  six  hours  for  a  child  of  a 
year  and  a  half  to  two  years  old.  This  remedy,  indeed,  may  sometimes 
be  used  with  advantage,  even  before  the  disorder  has  begun  to  decline, 
if  the  condition  be  such  as  I  have  just  referred  to,  namely,  fever  being 
absent,  and  the  bronchial  secretion  very  abundant,  even  though  the 
cough  is  violent.  In  other  cases,  in  which  the  cough  continues  violent 
after  the  other  symptoms  have  abated,  and  in  which,  though  there  is  no 
superabundance  of  secretion  in  the  air-tubes,  yet  the  attacks  of  cough 
often  end  with  the  rejection  of  a  considerable  quantity  of  mucus  from 
the  stomach,  and  loss  of  appetite  and  general  dyspeptic  symptoms  are 
present,  the  hydrochloric  acid  is  often  of  much  service.  It  has  been 
recommended  as  a  specific  agent  against  hooping-cough,  in  doses  of 
from  two  Ho  six  drachms  daily ;  but  I  have  never  employed  it  in  other 

1  See  Formula  No.  12,  p.  190. 


TREATMENT   OF    THE    THIRD    STAGE    OP   HOOPING-COUGH.  277 

than  moderate  doses,  such  as  it  would  be  administered  in  under  other 
circumstances.1 

(No.  18.) 

1  R  Acid.  Hydrochlor.  dil.   TT^xxxij. 

Tinct.  Opii,  r^iv. 

Syr.  Mori,  giv. 

Aquae  puree,  giiss.     M.     giij.  ter  die. 

If  the  cough  continue  frequent,  and  the  hoop  loud,  while  the  only 
signs  of  constitutional  disturbance  are  those  of  mere  weakness,  iron  will 
generally  put  a  stop  to  it  sooner  than  any  other  remedy.2     If,  however, 

(No.    19.) 

2  R  Mist.  Ferri  co.  giv. 

Tinct.  Scillae,  TT^xvj. 

Tinct.  Conii,  TT^xl. 

Mist.  Amygdalae,  ^ij.  £iij.     M.     giij.  ter  die. 

there  be  a  degree  of  feverishness,  or  of  gastro-intestinal  disorder,  which 
for  the  present  contraindicates  the  use  of  iron,  Battley's  liquor  cinchonae 
may  be  given  with  great  advantage,  in  combination  with  small  doses  of 
hydrocyanic  acid;3  while  every  attention  must  of  course  be  paid,  by 

(No.  20.) 

3  R  Acid.  Hydrocy.  dil.  TTLviij. 

Sodoe  Sesquicarb.  gr.  xij. 
Liq.  Cinchonae,  giss. 
Syr.  Aurantii,  giss. 

Aquae  Flor.  Aurant.  giij.  / 

Aquae  destil.  ^vj.     M.     £pj.  ter  die.     ( 

All  the  above  are  suited  for  children  of  two  years  old. 

mild  alteratives,  and  other  appropriate  means,  to  improve  the  condition 
of  the  digestive  organs. 

It  is  probably  unnecessary  to  enter  into  further  details,  to  specify 
minutely  the  diet  that  a  convalescent  requires,  or  to  refer  to  the  utility 
of  liniments  to  the  chest,  or  the  occasional  benefit  of  anodynes  at  night. 

There  still  remain  numerous  remedies  that  have  a  more  or  less  well- 
merited  reputation  in  cases  of  hooping-cough.  I  must  content  myself 
with  having  pointed  out  to  you  the  kind  of  weapons  that,  under  diffe- 
rent circumstances,  must  be  employed ;  and  must  leave  to  you  the  selec- 
tion of  the  one,  whose  form  and  size  may,  on  different  occasions,  seem 
to  you  most  fitting.  The  armoury  is  large  enough  to  yield  you  an 
ample  choice. 


278  PULMONARY  PHTHISIS. 


LECTURE    XXIV. 

Pulmonary  Phthisis — differences  exist  between  the  tuberculous  cachexia  in  the  child 
and  in  the  adult — Statistical  table  illustrating  its  peculiarities  in  early  life. — Ana- 
tomical characteristics  of  pulmonary  phthisis  in  the  child — frequency  of  miliary 
tubercle  and  of  grey  granulations  in  the  lung,  independent  of  each  other,  and  of  other 
forms  of  tubercle — frequency  of  tubercular  infiltration — rarity  of  cavities — frequent 
affection  of  bronchial  glands — description  of  each  of  these  peculiarities — changes  in 
tuberculous  bronchial  glands — perforation  of  bronchi,  and  elimination  of  tubercular 
matter. 

Symptoms  of  phthisis — their  differences  from  those  of  the  disease  in  the  adult — danger 
of  overlooking  its  early  stage,  or  of  mistaking  it  for  remittent  fever,  &c. — peculiarities 
of  its  subsequent  course. 

Bronchial  phthisis — its  characteristics — remarkable  fluctuations  in  its  course — occa- 
sional unexpected  recovery — case  of  its  occurrence,  attended  with  expectoration  of 
tubercular  matter — its  fatal  termination  usually  preceded  by  merging  of  its 
symptoms  in  those  of  general  pulmonary  phthisis — occasional  fatal  haemoptysis,  but 
this  accident  not  limited  to  cases  of  bronchial  phthisis. 

Phthisis  in  very  early  infancy — pulmonary  symptoms  often  obscured  by  signs  of 
generally  defective  nutrition. 

We  enter  to-day  on  the  examination  of  one  of  the  most  painfully 
interesting  diseases  with  which  we  have  to  do.  It  is  a  disease  that  we 
not  only  often  see  in  hospitals,  or  in  the  dwellings  of  the  poor,  but 
which  has  brought  grief  into  the  habitations  of  many  among  us,  and 
has  robbed  us  of  those  whom  we  most  dearly  loved ;  while  the  very  men- 
tion of  its  name  gives  rise  to  a  feeling  of  utter  hopelessness  as  to  its 
issue.  I  need  hardly  say  that  I  propose  to-day  to  call  your  attention 
to  Pulmonary  Consumption  or  Phthisis, — a  malady  that  attacks  per- 
sons of  all  ,ages,  of  both  sexes,  and  of  every  rank,  and  which,  under 
every  variety. of  condition,  medicine  seems  to  be  equally  unable  to  cure. 

It  may,  however,  occur  to  some  of  you  that,  important  though  this 
affection  is,  yet  in  speaking  of  it  I  am  transgressing  the  bounds  that  I 
set  myself,  when  I  proposed  to  treat  only  of  those  maladies  which  are 
either  limited  in  their  occurrence  to  the  period  of  childhood,  or  on  which 
the  early  years  of  the  patient  impress  some  well-marked  peculiarity. 
It  is  true,  indeed,  that  at  whatever  age  phthisis  comes  on,  it  presents 
the  same  grand  features,  it  works  the  same  kind  of  changes,  and  tends 
to  the  same  fatal  result.  But  yet  the  disease  in  the  young  subject  dis- 
plays differences  from  its  character  in  the  old,  sufficient  to  attract  the 
notice  of  the  observant ;  nor  are  these  differences  merely  curious,  but 
they  influence  our  prognosis  and  modify  our  treatment, — and  hence  it 
is  fitting  that  we  devote  some  time  to  their  examination. 

"  That  great  constitutional  malady,  of  which  pulmonary  consumption 
is  only  a  fragment,  plays  its  part,"  in  childhood  as  well  as  in  adult  age, 
"  most  conspicuously  in  the  lungs."  In  the  adult,  however,  the  lungs 
are  so  almost  invariably  the  seat  of  tubercular  deposit,  that  out  of  123 
cases,  M.  Louis  found  but  one  exception  to  the  rule,  that  if  tubercle 
exist  in  any  viscus,  it  will  be  discovered  also  in  the  lungs.  In  the  child, 
though  the  lungs  are  still  the  most  frequent  seat  of  tubercle,  yet  M. 


DIFFERENCE  BETWEEN   PHTHISIS   IN   THE   CHILD   AND   ADULT. 


279 


Louis'  law  no  longer  holds  good,  for  MM.  Rilliet  and  Barthez  found  47 
exceptions  to  it  out  of  312  instances  in  which  tubercle  was  discovered 
in  some  one  or  more  organs  of  the  body. 

The  first  great  difference,  then,  between  the  tubercular  cachexia  in 
childhood  and  in  adult  age,  consists  in  the  same  organs  not  being 
equally  liable  to  it  at  the  two  periods  of  life. 

The  following  table  will  place  this  difference  clearly  before  you.  It 
shows  the  proportion  per  cent,  in  which  different  viscera  were  the  seat 
of  tubercle  in  children  and  in  adults.  The  figures  in  the  first  column 
are  deduced  from  312  cases  which  form  the  basis  of  MM.  Rilliet  and 
Barthez'  essay  on  the  tuberculous  cachexia ;  those  in  the  second,  from 
the  123  cases  on  which  M.  Louis'  work  on  phthisis  is  founded ;  and  the 
third  contains  the  results  arrived  at  by  Lombard  on  an  examination  of 
100  adults. 


Of  100  instances  in  which  tubercle  was 


in  some 


of  the  viscera,  it  was  present  in- 


In  the  lungs 

"    bronchial  glands 

"    mesenteric 

11    small  intestines 

"    spleen , 

"    pleura •. 

"    peritoneum 

"    liver 

"    large  intestines 

"  membranes  of  the  brain 

"    kidneys 

"    brain 

"    stomach 

"  heart  and  pericardium.. 


Children  from 
1  to  15  years. 


According  to 

Rilliet  and 

Barthez. 


84 
79 
46 
42 
40 
34 
27 
22 
19 
16 
15 
11 
6 
8 


Adults  from  20  years  and 
upwards. 


According  to 
Louis. 


100 
28 
33 
33 
13 

2 

0 

0 
10 

0 

2 

0.8 

0 

0 


According  to 
Lombard. 


100 
9 
19 
0 
6 
1 
0 
1 
0 
2 
1 
2 
0 
0 


This  table  shows  not  only  that  the  liability  of  certain  organs  to  be- 
come the  seat  of  tubercle  is  different  in  childhood  from  what  it  is  in  the 
adult,  but  also  that  tubercle  is  simultaneously  deposited  in  a  greater 
number  of  organs'  in  the  young  than  in  the  old.  This  greater  intensity 
of  the  tuberculous  cachexia  in  early  life  is  a  fact  of  much  importance. 
It  explains  how  it  happens  that  death  sometimes  takes  place  in  the 
child,  before  tubercle  has  any  where  undergone  those  changes  which 
seem  almost  always  to  precede  the  fatal  event  in  the  adult.1 


1 1  have  thrown  together  into  the  following  note  some  details  with  reference  to  Phthisis 
in  early  life,  which,  though  far  too  few  to  warrant  the  deduction  of  any  positive  conclu- 
sions, may  not  be  without  value  as  furnishing  materials  for  comparison  with  the  results 
obtained  by  other  observers. 


280 


ANATOMICAL   PECULIARITIES   OF   PHTHISIS   IN   THE   CHILD.  ' 


These,  however,  are  not  the  only  peculiarities  of  the  disease  in  early 
life,  but  the  anatomical  characters  of  tubercle  in  the  lungs,  (and  of  this 
I  am  now  more  particularly  speaking)  differ  in  some  respects  in  the 
child  from  those  which  are  observed  in  the  grown  person. 

The  first  of  these  peculiarities  consists  in  the  frequency  with  which 


Table  o/189  Cases,  showing  influence  of  Sex  and  Age  in 


ing  to  Pulmonary  Phthisis. 


Total  Examinations 

Under 
1  year. 

From 
1-2. 

From 
2-3. 

From 
3-5. 

From 
5-10. 

From 
10-15. 

Total. 

M.     F. 

27     18 

8       8 

19     10 

M.    F. 

23     23 

7      7 

16     16 

M.    F. 

13     10 
4       5 
8       6 

M.    F. 

17     19 

6     11 

11       8 

M.    F. 

22     13 

14       8 

8       5 

M.    F.   |  M.          F. 
1       3      109       ft7 

Tubercle  present  in  chest,  in... 
Ditto,  not  present  in  chest,  in.. 

1     2 
0    1 

40    41 
62     46 

The  degree  of  the  tubercular  degeneration  was  not  the  same  in  all  cases  ;  but  is  stated 
to  have  been  slight  in  22,  moderate  in  20,  considerable  in  39;  proportions  which  were 
thus  distributed: — 


Slight , 

Moderate  .... 
Considerable 


Under 

From 

From 

From 

From 

From 

Total. 

1  year. 

1-2. 

2-3. 

3-5. 

5-10. 

10-15. 

M.    F. 

M.     F. 

M.    F. 

M.     F. 

M.    F. 

M.    F. 

M.          F. 

— 

2     0 

2     1 

3     4 

5     3 

1       1 

13       9 

1     2 

1     4 

0     2 

1     3 

3     3 

— 

6     14 

7     6 

4     3 

2     2 

2     4 

6     2 

0    1 

21     18 

In  the  above  81  cases,  the  forms  assumed  by  the  tubercular  deposit  were  as  follows  : — 


Grey  granulations 

Yellow  tubercle 

"         "         softened 

"         "        in  cretaceous  state... 

Tubercular  infiltration... 

Small  vomicae 

Large  cavities 

Tubercle  of  bronchial  glands 12 


GO 

a 
o 

S>   S3 
*\ 

|| 

Iss 

Yellow 

ubercle  in 

retaceous 

state. 

.2.2 

11 

02  O 
> 

M 

•H   — 1 
©  '3    TO 

I  §1 

O 

fci  « 

EHm 

H 

29 

16 

5 

7 

3 

3 

12 

15 

40 

7 

— 

16 

8 

2 

38 

5 

1 
7 

7 

9 

1 

3 

7 

— 

9 

16 

3 

20 

7 

6 

20 

3 

8 

7 

— 

7 

13 

3 

13 

3 

2 

— 

— 

6 

3 

8 

3 

12 

38 

9 

— 

20 

13 

8 

72 

In  16  of  the  72  cases  in  which  the  bronchial  glands  were  the  seat  of  tubercle  the  pul- 
monary tissue  was  unaifected;  and  this  although  thrice  the  deposit  in  the  glands  was 
universal,  and  in  one  of  the  three  cases  had  gone  on  to  softening. 

The  tubercle  of  the  glands  was  incipient  in  .  .  .  .16 

"  "  "  general  in  .  .  .  .  .31 

"  "  "    had  reached  stage  of  softening  in  .  .     18 

"  "  "     was  in  a  firm,  friable,  cheesy  state  in  .  .2 

u  "  "  undergoing  cretaceous  change  in  .  .6 


ANATOMICAL  PECULIARITIES   OP   PHTHISIS   IN   THE   CHILD.  281 

grey  granulations  and  crude  miliary  tubercles  exist  in  the  lungs  inde- 
pendent of  each  other,  and  of  any  other  form  of  tubercular  deposit.  In 
the  adult,  M.  Louis1  discovered  miliary  tubercles  alone  only  in  2  out  of 
123  cases  of  phthisis  ;  and  grey  granulations  alone  only  in  5  more.  In 
the  child,  MM.  Billiet  and  Barthez,2  found  miliary  tubercles  alone  in 
107,  and  grey  granulations  alone  in  36  out  of  265  cases;  and  my  own 
observations,  which  are  based  on  81  cases,  yield  18  instances  of  the 
presence  of  miliary  tubercles  alone,  and  13  of  the  presence  of  grey  gra- 
nulations alone  in  the  tissue  of  the  lungs. 

The  great  rapidity  with  which  the  deposit  and  development  of 
tubercle  often  take  place  in  early  life,  is  doubtless  one  chief  cause  of  this 
peculiarity.  If  we  examine  the  lungs  of  an  adult  aifected  with  the 
tuberculous  cachexia,  we  shall  often  observe  their  lower  lobes  containing 
grey  semi-transparent  granulations  ;  as  we  advance  higher,  we  shall  pro- 
bably find  that  the  granulations  have  lost  much  of  their  transparency, 
and  that  they  present  a  yellowish  spot  in  their  centre,  while  near  to  the 
apex  of  the  lung  the  deposit  exists  in  no  other  form  than  that  of  bodies 
presenting  the  whitish  yellow  colour  and  friable  texture  characteristic 
of  crude  tubercle.  These  appearances  seem  to  betoken  that  the  deposit 
of  tubercle  has  taken  place  slowly  and  at  successive  periods,  so  that  those 
tubercles  which  occupy  the  apex  of  the  lung  are  already  approaching 
maturity  at  a  time  when  the  disease  is  just  beginning  to  invade  the 
lower  lobes.  In  the  child,  however,  it  not  seldom  happens  that  all  the 
lobes  of  both  lungs  present  a  nearly  equal  amount  of  tuberculous 
deposit,  and  that  this  is  seen  to  be  nearly  equally  advanced  in  all.  Thus 
we  may  find  the  grey  granulation  diffused  in  about  the  same  abundance 
through  all  parts  of  the  lungs,  and  all  equally  transparent ;  or  we  may 
observe  each  granulation  presenting  a  yellow  spot  in  its  centre ;  or  the 
change  may  be  complete,  and  crude  yellow  tubercle  may  be  everywhere 
present. 

Thi3  same  fact,  of  the  acute  course  of  tuberculization  of  the  lungs  in 
children,  receives  a  further  illustration  from  the  second  anatomical  pecu- 
liarity of  the  disease ;  namely,  the  great  frequency  with  which  yellow 
infiltration  of  tubercle  is  observed  in  early  life  ;  MM.  Rilliet  and  Bar- 
thez having  met  with  it  in  88  out  of  265  children,  or  in  33  per  cent. ; 
and  I,  in  20  out  of  81,  or  in  25  per  cent.  It  is  a  form  of  degeneration 
of  the  lung  which  seldom  exists  alone,  but  is  almost  invariably  asso- 
ciated with  grey  granulations  or  yellow  tubercle,  and  usually  co-exists 
with  a  state  of  very  far  advanced  tuberculization  of  the  bronchial 
glands.  It  is  often  limited  to  one  lobe,  generally  the  upper  :  or  some- 
times the  middle  lobe,  in  those  cases  in  which  the  right  lung  is  the  seat 
of  the  disease.  Those  portions  of  the  lung  which  are  affected  by  it 
become  converted  into  a  firm  solid  mass,  having  much  both  of  the  colour 
and  consistence  of  cheese,  presenting  a  smooth  surface  when  cut,  and 
by  its  solidity  compressing  the  bronchial  tubes  which  traverse  it,  so  as 
considerably  to  reduce  their  calibre.  If  the  patient's  life  be  prolonged, 
a  process  of  softening  generally  takes  place,  the  tissue  breaks  down, 
and  a  cavity  is  the  result,  the  parietes  of  which  are  formed  by  solid 

1  Reckerches  sur  la  Phthisie,  p.  3.  2  Op.  cit.,  vol.  iii.,  p.  221  and  p.  227. 


282  FREQUENCY   OF   TUBERCULAR   INFILTRATION. 

tubercle.  At  other  times,  especially  if  the  disease  run  its  course  with 
great  rapidity,  the  lung  thus  infiltrated  seems  to  undergo  a  different 
kind  of  softening,  which  does  not  lead  to  the  formation  of  a  central 
cavity,  but  pervades  its  tissue  throughout,  which  then  presents  a  reddish 
yellow,  or  rose-coloured  tint,  and  breaks  down  easily  into  a  kind  of 
putrilage,  as  if  the  changes  produced  were  the  result  of  a  mixture  of 
true  pneumonic  hepatization,  and  of  tubercular  degeneration.  Cases 
of  this  sort  go  far  towards  substantiating  the  correctness  of  M.  Roki- 
tansky's  theory,  with  reference  to  the  nature  of  this  tubercular 
infiltration,  as  compared  with  the  ordinary  form  of  tubercular  deposit. 
He  conceives  that  the  deposit  of  tubercle  in  the  form  of  grey  or  yellow 
granulations  takes  place  in  the  interstitial  cellular  tissue  of  the  lung ; 
while  in  the  case  of  tubercular  infiltration,  the  matter  poured  out  into 
the  interior  of  the  pulmonary  vesicles  during  an  attack  of  pneumonia 
becomes  converted  into  tubercle  under  the  influence  of  the  tubercular 
cachexia. 

A  third  peculiarity  of  "phthisis  in  the  child,  as  contrasted  with  the 
same  disease  in  the  adult,  consists  in  the  greater  rarity  of  cavities  in 
the  lungs  during  early  life.  Of  123  cases  which  form  the  basis  of  M. 
Louis'  work  on  phthisis,  cavities  were  present  in  by  far  the  majority  of 
instances ;  and  though  the  numbers  are  not  exactly  stated,  the  excep- 
tions would  seem  to  have  been  but  very  few.  Out  of  265  cases, 
however,  that  came  under  the  notice  of  MM.  Rilliet  and  Barthez,  only 
76,  or  28.6  per  cent.,  presented  cavities  in  the  lungs;  and  they  existed 
in  only  16  of  the  81  cases  which  came  under  my  own  observation. 
These  cavities  sometimes  resemble  those  which  we  usually  meet  with 
in  the  adult ;  and  this  is  especially  the  case  with  children  above  six 
years  of  age,  in  whom,  indeed,  the  general  characters  of  phthisis 
approximate  closely  to  those  of  the  same  disease  in  the  grown  person. 
In  other  instances,  they  are  not  so  much  caverns,  as  very  small  excava- 
tions (vacuoles,  as  the  French  call  them,)  produced  by  the  softening  of 
small  tuberculous  deposits.  Such  excavations  communicate  with  the 
bronchi  and  with  each  other,  and  are  sometimes  exceedingly  numerous, 
but  do  not  occasion  such  a  destruction  of  the  pulmonary  tissue  as  to 
produce  any  where  a  cavity  of  considerable  dimensions.  This  appear- 
ance is  one  which  MM.  Rilliet  and  Barthez  were  the  first  to  describe. 
It  is  not  frequent,  and  has  only  once  or  twice  come  under  my  notice. 
Besides  these  two  forms  of  cavity  there  is  a  third,  to  which  I  have 
already  referred,  namely,  that  produced  by  softening  of  the  yellow 
tubercular  infiltration,  which  is  more  commonly  met  with  in  very  early 
life  than  subsequently.  Cavities  of  this  kind  sometimes  form  with  great 
rapidity,  and  attain  a  considerable  size.  The  whole  of  one  lobe  of  the 
lung  may  even  become  converted  into  a  sac,  which  is  often  almost  or 
quite  empty,  whilst  its  parietes  are  formed  by  little  besides  the  pleura 
and  the  fibrous  capsule  of  the  lung,  with  a  very  thin  lining  of  dense 
tubercular  matter.  It  is  far  from  unusual  to  meet  with  cavities  of  this 
kind  in  the  bodies  of  infants  only  a  few  months  old,  who  have  never 
thriven,  but  have  presented  few  signs  of  phthisis,  with  the  excep- 
tions of  progressive  loss  of  flesh  and  strength,  and  somewhat  hurried 
respiration.  , 


COMPARATIVE  RARITY   OF   CAVITIES   IN   THE   LUNGS.  283  ' 

The  last  anatomical  peculiarity  of  phthisis  in  infancy  and  childhood 
to  which  I  shall  direct  your  attention,  consists  in  the  abundant  deposit 
of  tubercle  in  the  bronchial  glands,  and  the  changes  to  which  that 
deposit  gives  rise.  Even  in  the  adult,  tubercle  is  deposited  in  the 
bronchial  glands  in  about  a  fourth  of  all  cases  of  phthisis,  but  the 
deposit  there  is  subsidiary  to  its  deposit  in  the  lungs.  In  the  child, 
however,  this  is  far  from  being  always  the  case ;  but  the  disease  in  the 
glands  is  often  as  important  as  that  in  the  lungs,  sometimes  much  more 
considerable. 

The  tubercular  deposit  does  not  appear  to  begin  simultaneously  in 
all  the  glands,  nor  to  advance  in  all  with  the  same  rapidity;  but  those 
about  the  bifurcation  of  the  trachea,  and  close  to  the  primary  bronchi, 
are  usually  the  first  affected ;  and  the  disease  in  them  often  attains  a 
more  advanced  stage  than  elsewhere.  The  state  in  which  the  glands 
are  most  frequently  met  with  is  one  of  tubercular  infiltration,  the 
whole  of  their  substance  being  converted  into  a  firm,  resistant  matter, 
resembling  a  portion  of  lung  which  has  been  the  seat  of  tubercular  infil- 
tration ;  and  this  even  although  the  number  of  affected  glands  be  but 
small,  and  though  the  lungs  be  but  little  or  not  at  all  involved  in  the 
disease.  Sometimes,  however,  we  may  meet  with  the  affection  in  an 
incipient  state,  and  it  is  then  usual  to  find  the  glands  which  it  has 
attacked  somewhat  enlarged  and  injected,  and  their  tissue  infiltrated 
with  fluid,  and  less  firm  than  natural.  The  tubercular  deposit  does  not 
proceed  invariably  from  the  centre  to  the  circumference,  but  frequently 
two  or  three  small  deposits  may  be  discerned  at  different  parts  of  the 
same  gland;  or  the  tubercular  matter  may  be  accumulated  entirely  at 
one  end  of  the  gland,  while  its  other  extremity  is  merely  softened  and 
injected.  Even  when  the  disease  starts  from  several  points  it  is  not 
often  that  the  deposit  presents  the  distinctly  circumscribed  form  of 
miliary  tubercle,  and  still  less  often"  that  of.  grey  granulation;  but  it 
generally  presents  the  character  of  tubercular  infiltration  which  had 
taken  place  at  the  same  time  in  two  or  three  different  situations. 
Sometimes  it  is  impossible  to  distinguish  any  one  spot  as  that  from 
which  the  disease  started,  but  the  whole  tissue  of  the  gland  presents  a 
whitish  hue,  which  appears  due  to  the  general  infiltration  of  tuber- 
culous matter.  Whatever  may  have  been  the  mode  in  which  the 
deposit  of  tubercle  began,  the  tendency  of  the  advance  of  the  disease 
is  to  convert  the  entire  substance  of  the  gland  into  firm  tuberculous 
matter,  in  which  no  trace  of  the  original  tissue  can  be  detected.  This 
metamorphosis  of  the  gland  is  attended  with  considerable  increase  of 
its  size ;  the  enlargement,  however,  being  much  greater  in  the  case  of 
those  glands  which  are  situated  externally  to  the  lungs,  than  those 
which  aret  imbedded  in  the  pulmonary  substance.  The  enlargement  of 
the  glands  is  not  attended,  as  might  have  been  anticipated  beforehand, 
with  a  thinning  of  their  original  delicate  cellular  envelope,  but  this 
increase  in  density  and  firmness,  while  at  the  same  time  it  acquires  a 
very  considerable  thickness.  Most  of  the  glands  which  have  become 
converted  into  tubercle  are  enclosed  within  a  cyst  a  line  or  more  in 
thickness,  and  extremely  resistant ;  its  inner  surface  being  smooth,  of 
a  bright  rose  tint,  and  sometimes  presenting  a  considerable  degree  of 
vascularity. 


284  ANATOMICAL   CHARACTERS   OF   BRONCHIAL  PHTHISIS. 

In  a  large  proportion  of  cases  in  which  tubercle  is  found  in  the  bron- 
chial glands,  it  has  not  passed  beyond  the  crude  stage ;  but  if  life  be 
not  cut  shoi>t  by  the  advance  of  phthisis  in  the  lungs,  a  process  of 
softening  next  commences ;  and  the  softening  usually,  though  not 
invariably,  begins  at  the  centre  of  the  glands,  and  extends  towards 
their  circumference.  The  softening  is  seldom  found  equally  advanced 
in  all  the  glands  ;  but  in  some,  a  small  central  cavity  containing  liquid 
tubercle  is  surrounded  by  a  thick  wall  of  solid  matter ;  while  in  others, 
the  whole  substance  has  been  softened,  and  the  gland  is  no  longer  any 
thing  else  than  a  cyst  containing  a  quantity  of  puriform  fluid.  When 
tubercle  deposited  in  the  lung  has  undergone*the  process  of  softening, 
an  effort  is  made  by  nature  to  get  rid  of  the  morbid  matter,  which  is 
expectorated  ;  and  the  cavity,  thus  emptied  of  its  contents,  now  and 
then  cicatrizes,  and  the  patient  is  cured.  The  cases  of  cure,  indeed, 
bear  but  a  very  small  proportion  to  those  in  which  death  takes  place, 
for  in  general,  fresh  deposits  of  tubercle  successively  undergo  this 
softening,  until  but  a  comparatively  small  portion  of  the  lung  remains 
unaffected  by  the  disease ;  or  the  abundant  secretion  from  the  bronchial 
tubes  exhausts  the  patient,  or  death  ensues  from  the  degree  to  which 
other  organs  are  implicated  in  the  tuberculous  cachexia.  When  the 
bronchial  glands  are  the  seat  of  the  disease,  a  similar  effort  is  made  to 
eliminate  the  morbid  matter  from  the  system  ;  and  many  circumstances 
concur  to  render  this  a  more  hopeful  task  than  it  is  when  the  pulmonary 
substance  itself  is  the  seat  of  the  disease. 

The  means  by  which  this  is  effected  deserve  to  be  examined.  When 
tuberculization  of  the  bronchial  glands  has  attained  an  advanced  stage, 
we  generally  observe  a  process  of  thickening  and  infiltration  to  have 
commenced  in  the  cellular  tissue  around  each  gland,  by  no  means  unlike 
that  which  takes  place  in  the  pia  mater  at  the  base  of  the  brain  in 
cases  of  tubercular  hydrocephalus.  This  cellular  tissue  often  assumes 
a  greyish  semi-transparent  aspect,  and  presents  a  number  of  minute 
granules  of  tubercle  diffused  through  it.  By  a  process  of  combined 
inflammation  and  tuberculization,  the  connection  between  the  gland 
and  the  adjacent  bronchial  tube  becomes  extremely  intimate.  The  cel- 
lular tissue  in  the  intervals  between  the  bronchial  rings  becomes  next 
infiltrated  with  tubercle,  and  is  then  the  first  part  of  the  wall  of  the 
bronchial  tube  which  disappears  during  a  process  of  absorption  that 
advances  from  without  inwards.  The  cellular  tissue  sometimes  becomes 
quite  removed  before  the  cartilages  of  the  bronchi  are  much  affected  ; 
but  in  process  of  time  they  too  become  absorbed,  and  the  perforation 
of  the  tube  is  then  complete ;  the  tuberculated  gland,  however,  block- 
ing up  the  aperture  in  its  walls,  and  projecting  into  its  cavity.  The 
next  step  consists  in  the  thinning  of  the  envelope  of  the  gjand,  and 
the  next  is  the  discharge  of  its  contents  into  the  tube ;  and  the  cyst 
then  in  all  probability  collapses  and  becomes  applied  to  the  outside  of 
the  bronchus,  so  as  to  form  a  part  of  its  parietes.  But  we  are  still  in 
want  of  some  exact  observations  as  to  this  last  stage  in  the  cure  of 
bronchial  phthisis. 

This  process  does  not  take  place  with  equal  frequency  in  all  the  bron- 
chial glands ;  for  those  which  are  situated  around  the  trachea,  and 


PERFORATION   OF   THE    BRONCHIAL   TUBES.  285 

•wholly  external  to  the  lung,  meeting  with  no  obstacle  to  their  increase 
in  size,  often  attain  a  great  magnitude  without  at  all  compromising  the 
integrity  of  the  trachea.  Those,  however,  which  are  in  contact  with 
the  secondary  and  tertiary  bronchi,  and  are  imbedded  in  the  pulmonary 
substance  (which  prevents  their  attaining  any  considerable  size),  not 
infrequently  perforate  the  tube  in  the  manner  above  described, — and 
this  not  only  after  they  have  become  softened,  but  even  while  the 
tubercle  they  contain  is  still  in  the  crude  state. 

Although  the  progress  of  the  tubercular  degeneration  is  most  obvious 
in  those  glands  which  are  situated  near  to  the  larger  air-tubes,  yet  it  is 
by  no  means  limited  to  them,  but  is  in  many  instances  observed  also  in 
the  pulmonary  glands  which  are  imbedded  in  different  parts  of  the  sub- 
stance of  the  lungs.  They  do  not,  however,  become  enclosed  within  a 
cyst  as  dense  and  resisting  as  that  which  surrounds  the  tuberculous 
bronchial  glands  ;  while  in  a  great  number  of  instances  the  pulmonary 
substance  for  a  short  distance  around  them  presents  a  far  more  abundant 
tubercular  deposit  than  is  apparent  in  any  other  part  of  the  lungs.  If 
a  tuberculous  gland,  thus  imbedded  in  the  tissue  of  the  lung,  should 
become  softened,  the  excavation  thereby  produced  may  easily  be  mis- 
taken for  a  cavity  in  the  lung  itself.  A  pulmonary  cavity  of  such  small 
dimensions,  however,  is  hardly  ever  solitary,  unless  it  proceeds  from 
the  softening  of  tubercular  infiltration ;  but  the  deposit  of  tubercle 
which  takes  place  in  the  neighbourhood  of  a  diseased  pulmonary  gland 
is  always  in  the  form  of  distinct  deposits — not  of  tubercular  infil- 
tration. 

Tuberculization  of  the  glands  does  not  occasion  perforation  merely  of 
the  bronchial  tubes,  but  in  some  rare  instances  the  oesophagus,  trachea, 
and  pulmonary  artery,  have  been  perforated  by  the  same  process  as  is 
usually  limited  to  the  air-tubes. 

In  some  cases  in  which  tuberculization  has  never  advanced  far,  it 
comes  to  a  stand-still,  and  the  tubercle  itself  undergoes  the  cretaceous 
change.  This,  however,  is  a  rare  occurrence,  for  it  has  come  under  my 
notice  only  in  six  out  of  seventy-two  cases;  though,  on  the  other  hand, 
it  is  more  frequent  than  in  the  lung,  in  which  it  has  come  under  my 
notice  in  the  child  only  in  one  instance.  In  two  other  instances,  the 
contents  of  the  bronchial  glands,  though  not  actually  cretaceous,  were 
very  dry  and  friable,  as  if  the  more  fluid  constituents  of  the  tubercle 
had  been  removed,  and  the  cretaceous  change  were  about  to  commence. 
This  change  has  never  come  under  my  notice  as  having  taken  place  in 
any  gland  which  had  attained  considerable  size  in  consequence  of  the 
deposit  of  tubercle  in  it,  nor  have  I  ever  seen  it  when  the  tuberculization 
of  the  glands  was  general,  or  when  the  lungs  showed  evidence  of  general, 
or  advanced,  phthisical  disease. 

The  symptoms  of  'phthisis  in  early  life  resemble  in  many  respects 
those  which  characterise  the  disease  in  adult  age,  while  the  points  of 
difference  become  fewer  and  fewer  in  proportion  as  the  child  grows  older, 
until  they  cease  altogether  at  the  period  of  puberty.  During  childhood, 
however,  even  those  cases  which  run  a  course  most  similar  to  that  of 
ordinary  phthisis  in  the  adult  are  in  general  distinguished  by  the  absence 
of  haemoptysis  at  any  stage  of  the  affection, — the  absence  of  expecto- 


286  SYMPTOMS   OF   PHTHISIS. 

ration,  or  its  very  rare  occurrence, — the  comparative  slightness  of  the 
cough,  and  the  rarity  of  those  colliquative  sweats  which  so  much  exhaust 
the  grown  person.  In  many  instances  the  child  droops,  loses  its  appetite, 
and  flesh,  and  strength,  and  complains  of  vague  pains  in  the  chest  and 
abdomen  for  many  weeks  before  the  occurrence  of  cough  excites  any 
apprehension  that  the  lungs  are  the  seat  of  disease.  When  the  cough 
does  come  on,  it  is  slight,  short,  and  dry,  and  attracts  attention  by  its 
frequency,  rather  than  by  the  discomfort  which  it  occasions  the  child. 
Its  usual  amusements  cease  to  occupy  the  child,  who  sits  about,  listless 
and  fretful  in  the  day-time,  while  the  skin  often  grows  hot  and  dry,  and 
the  lips  become  parched  as  night  approaches ;  but  there  is  so  little  that 
is  definite  in  these  symptoms,  that  they  are  not  infrequently  supposed 
to  indicate  the  existence  of  remittent  fever,  or  to  be  due  to  the  presence 
of  worms  in  the  intestines. 

It  is  important  to  bear  in  mind,  that  strumous  dyspepsia,  as  it  has 
been  called  by  many  writers,  is  of  more  frequent  occurrence  in  child- 
hood than  in  adult  age,  and  that  its  symptoms  may  be  all  that  marks 
the  advance  of  phthisis  in  the  lungs  until  within  a  month  or  two  of  the 
patient's  death.  A  definite  commencement  can  almost  always  be  assigned 
to  an  attack  of  remittent  fever;  and  the  great  heat  of  the  skin,  the 
very  rapid  pulse,  the  intense  thirst,  and  the  delirium  at  night,  which 
attend  it  even  in  its  less  severe  forms,  are  symptoms  which,  if  borne  in 
mind,  would  prevent  our  mistaking  for  it  those  slighter  and  more  vague 
ailments  that  are  experienced  during  the  first  stage  of  phthisis.  The 
referring  the  symptoms  of  incipient  consumption  to  the  presence  of 
worms  in  the  intestinal  canal,  is  a  mistake  even  less  excusable ;  the 
natural  temperature  of  the  skin,  and  natural  frequency  of  the  respira- 
tion,— the  appetite  at  one  time  as  ravenous  as  it  is  deficient  at  another, 
— the  tongue  either  clean  and  moist,  or  else  thickly  coated, — the  con- 
dition of  the  bowels,  which  is  generally  one  of  constipation,  and  the 
marked  relief  that  almost  always  follows  the  action  of  purgatives, — are 
indications  of  the  presence  of  worms  sufficiently  characteristic  to  guard 
the  attentive  observer  from  error. 

Fluctuations  take  place  in  the  child's  condition,  and  a  casual  attack 
of  bronchitis  often  seems  to  be  the  exciting  cause  of  that  aggravation 
of  the  pulmonary  symptoms  which  is  observed  before  long.  The  respi- 
ration now  becomes  habitually  quicker  than  natural,  instead  of  merely 
being  easily  accelerated,  and  is  often  attended  with  considerable 
wheezing :  the  cough  grows  more  frequent  and  lasts  longer,  but  is  still 
in  most  instances  unattended  with  expectoration,  owing  to  the  circum- 
stance that  the  child  almost  always  swallows  those  matters  which  the 
adult  would  spit  up.  The  loss  of  flesh,  and  the  decay  of  strength, 
advance  even  more  rapidly  than  the  signs  of  pulmonary  disease.  Well- 
marked  hectic,  however,  is  infrequent ;  and  if  night  sweats  occur,  they 
are  often  limited  to  the  head  and  face.  Towards  the  elose  of  the  disease 
the  mouth  often  becomes  aphthous,  especially  in  infants :  but  though 
diarrhoea  sometimes  occurs,  it  does  not  often  seem  to  contribute  so 
much  to  the  exhaustion  of  the  child  as  to  that  of  the  adult,  and  that 
alternation  of  diarrhoea  and  hectic  sweats,  which  is  often  observed  in 
the  grown  person,  is  seldom  or  never  observed  in  the  child.     When 


PECULIARITIES   IN   THE    SYMPTOMS   OF   BRONCHIAL   PHTHISIS.         287 

death  at  length  takes  place,  it  either  occurs  from  exhaustion,  or  suc- 
ceeds to  some  intercurrent  attack  of  bronchitis  or  pneumonia. 

In  those  cases  in  which  tubercle  has  been  deposited  in  great  abun- 
dance in  the  bronchial  glands,  constituting  what  is  called  bronchial 
phthisis,  the  symptoms  deviate  still  more  from  those  which  are  usually 
observed  in  the  adult.  Bronchial  phthisis  occurs  in  its  best  marked 
form  between  the  ages  of  two  and  six  years,  although,  as  it  is  scarcely 
necessary  to  observe,  tuberculization  of  the  glands  is  by  no  means 
limited  to  that  age.  Its  symptoms  in  many  instances  first  become  dis- 
tinctly evident  after  some  severe  bronchitic  seizure,  which  either 
accompanied  measles  or  came  on  without  any  apparent  exciting  cause. 
In  other  cases,  although  the  commencement  of  the  affection  is  not 
clearly  traceable  to  a  single  attack  of  severe  bronchitis,  yet  the  patients 
in  whom  it  occurs  had  in  all  probability  been  subject  to  frequent  returns- 
of  catarrh  or  bronchitis,  which,  though  not  alarming  in  their  symptoms, 
yet  left  behind  them  a  cough  that  never  entirely  subsided.  By  degrees 
this  cough  becomes  severer :  it  returns  in  paroxysms  not  unlike  those 
of  pertussis  :  it  sometimes  induces  efforts  to  vomit,  and  can  scarcely  be 
distinguished  from  the  cough  of  the  earlier  stages  of  hooping-cough. 
The  respiration  grows  habitually  oppressed  and  wheezing,  the  face 
becomes  puffed  and  swollen,  the  veins  of  the  neck  distended,  just  as  in 
patients  with  heart  disease,  and  the  superficial  vessels  of  the  thorax 
become  enlarged,  just  as  those  of  the  abdomen  do  in  cases  of  ascites, 
or  of  mesenteric  disease. 

The  great  fluctuations  which  take  place  in  the  condition  of  the  patient 
constitute  one  of  the  most  striking  characteristics  of  this  form  of 
phthisis.  Attacks  of  bronchitis  sometimes  come  on,  during  which  the 
respiration  becomes  painfully  accelerated  and  oppressed,  and  the  paroxys- 
mal cough  is  merged  for  a  time  in  a  constant  hacking,  or  in  suppressed 
attempts  at  coughing.  These  bronchitic  symptoms,  which  often  seem 
to  threaten  life,  and  which  sometimes  actually  destroy  it,  clear  up  by 
degrees  in  the  majority  of  cases,  but  leave  the  child  with  a  severer 
cough  and  a  more  hurried  respiration  than  before,  while  it  loses  flesh 
rapidly,  and  not  infrequently  sweats  a  good  deal  about  the  head  and 
upper  part  of  the  trunk.  Accommodation  of  posture,  too,  in  many 
instances  becomes  necessary  to  the  comfort  of  the  little  patient,  who 
perhaps  can  breathe  only  when  supported  in  its  mother's  lap,  or 
when  much  propped  up  in  bed.  It  is  seldom,  when  the  disease  has 
reached  this  degree  of  severity,  that  there  is  not  also  so  large  a 
measure  of  tuberculous  affection  of  the  lungs  and  other  viscera  as  to 
render  recovery  quite  hopeless,  and  the  characteristic  signs  of  bronchial 
phthisis  become  lost  by  degrees  in  those  of  ordinary  consumption. 
Sometimes,  however,  a  long  pause  takes  place  in  the  progress  of  the 
disease,  even  though  thus  far  advanced :  the  cough,  which  had  acquired 
fresh  intensity,  gradually  abates, — the  respiration  is  no  longer  habitually 
wheezing — the  patient  can  repose  in  any  attitude, — the  flesh  lost  is 
regained, — and,  were  it  not  that  cough  still  continues,  though  less 
frequent  and  less  severe,  that  the  breathing  is  more  hurried  than 
natural,  and  that  auscultation  contributes  still  further  to  undeceive  us, 
— we  might  fancy  that  all  ground  for  anxiety  was  passing  away,  and 


288  SYMPTOMS   OF  BRONCHIAL  PHTHISIS. 

that  the  child  was  on  the  high  road  towards  recovery.  In  some  cases, 
too,  in  which  symptoms  such  as  have  been  described  are  observed, 
recovery  does  eventually  take  place.  It  is  seldom  possible  to  say  in 
any  case  by  what  means  this  recovery  is  brought  about;  sometimes,  no 
doubt,  the  tubercular  matter  makes  its  way  into  the  air-tubes,  and  is 
got  rid  of  by  expectoration.  Once  I  observed  the  disappearance  of 
most  well-marked  general  signs  of  consumption,  in  the  case  of  a  girl 
eight  years  old,  during  the  copious  expectoration  of  a  tenacious  mucus, 
in  which  were  small  quantities  of  a  substance  like  broken-down  cheese, 
or  grains  of  boiled  rice,  and  which  alternated  with  an  expectoration  of 
thick,  puriform  matter,  more  or  less  tinged  with  blood.  In  the  case  of 
this  child  an  attack  of  measles,  while  in  her  seventh  year,  had  been 
succeeded  by  cough,  the  formation  of  abscesses  in  her  neck,  and  a 
frequent,  puriform,  and  sanguineous  discharge  from  her  nose.  These 
abscesses  had  not  been  long  healed  when  her  mother's  alarm  was  excited 
by  her  expectorating  blood  mixed  with  the  phlegm  which  she  brought 
up  when  coughing.  Though  not  much  emaciated,  the  child  looked 
unhealthy  ;  ber  pulse  was  very  feeble,  and  there  were  many  small 
petechias  on  her  extremities.  The  lungs,  however,  were  tolerably  free 
from  disease  ;  for  nothing  more  was  heard  during  auscultation  than  a 
good  deal  of  rhonchus  mixed  with  some  moist  sounds,  which  were  most 
evident  at  the.  upper  part  of  the  chest.  Expectoration  such  as  I  have 
described  continued  for  nearly  three  months,  in  the  course  of  which 
time  the  child  by  degrees  lost  her  cough,  and  gained  strength  under 
the  use  of  steel  and  other  tonics.  Two  years  afterwards  no  ausculta- 
tory signs  of  disease  were  perceptible,  except  a  little  creaking  under 
both  clavicles ;  and  at  the  end  of  five  years  even  this  disappeared. 

The  fatal  termination  of  bronchial  phthisis  usually  takes  place  in 
consequence  of  the  lungs  becoming  seriously  involved  in  the  tubercular 
disease,  though  life  is  sometimes  suddenly  cut  off  by  haemoptysis,  owing 
to  the  perforation  of  one  of  the  larger  vessels  of  the  thorax  by  a  tuber- 
culated  bronchial  gland.  It  must  not,  however,  be  supposed  that  this 
is  the  only  means  by  which  fatal  haemorrhage  is  produced,  for  it  takes 
place  in  other  instances  under  precisely  the  same  circumstances  as  in 
the  adult.  Five  cases  of  fatal  haemoptysis  have  come  under  my  notice 
in  children ;  but  in  three,  no  examination  was  made  after  death.  In 
the  fourth  case,  which  was  that  of  a  boy  between  five  and  six  years  old, 
who  died  at  the  end  of  nine  months'  illness,  blood  pouring  in  abundance 
from  his  nose  and  mouth,  the  amount  of  disease,  both  of  the  lungs  and 
bronchial  glands,  was  very  considerable;  but  no  large  vessel  had  been 
perforated,  and  it  was  not  possible  satisfactorily  to  determine  the  source 
of  the  haemorrhage.  In  the  fifth  case,  that  of  a  little  boy  five  years  old, 
in  whom  symptoms  of  pneumonia  had  supervened  upon  previous  signs 
of  phthisis,  the  source  of  the  bleeding  in  the  single  and  fatal  attack 
of  haemoptysis  which  took  place  at  a  time  when  he  seemed  recovering, 
likewise  eluded  the  most  careful  anatomical  investigation. 

A  very  considerable  degree  of  tuberculization  of  the  bronchial  glands, 
is  by  no  means  uncommon  even  in  very  early  infancy ;  but  it  then 
generally  forms  only  a  part  of  such  extensive  tubercular  disease,  that 
its  special  symptoms  are  lost  in  those  of  the  general  malady.     In  such 


PHTHISIS   CONTINUED.  289 

cases,  too,  it  frequently  occurs  that  the  signs  of  thoracic  disease  are 
almost  entirely  merged  in  those  of  generally  defective  nutrition.  The 
existence  even  of  a  large  cavity  in  the  lung  may  be  announced  in  early 
infancy  by  nothing  more  serious  than  some  acceleration  of  the  breathing 
and  an  occasional  short  cough ;  while  the  frequent  vomiting, — the 
irregular,  often  relaxed,  condition  of  the  bowels, — the  unhealthy  evacu- 
ations,— the  red  tongue,  and  the  aphthous  state  of  the  mouth, — may 
direct  the  attention  almost  exclusively  to  the  condition  of  the  digestive 
organs. 

Many  points  still  remain  for  our  investigation,  but  we  must  postpone 
their  consideration,  and  the  study  of  the  auscultatory  phenomena  of 
the  disease,  to  the  next  lecture. 


LECTUEE    XXV. 

Phthisis,  continued. — Peculiarities  of  its  auscultatory  signs  in  early  life — some  of  less 
value  than  in  the  adult — influence  of  tuberculous  bronchial  glands  in  exaggerating  the 
signs  of  disease  of  the  lung — difficulty  in  appreciating  some  signs  which  are  "well 
marked  in  the  adult — sign  peculiar  to  early  life. 

Different  forms  of  phthisis — acute  phthisis  ;  illustrative  case— tuberculous  pneumonia — 
bronchitis  grafted  on  phthisis  may  lead  to  an  over-estimate  of  the  tuberculous  disease. 

Duration  of  phthisis ;  its  course  sometimes  extremely  chronic — cases  in  illustration. — 
Modes  of  death  in  phthisis — head  symptoms  sometimes  precede  death,  independent  of 
cerebral  disease. 

Prophylaxis,  and  treatment  of  phthisis. 

It  would  be  little  better  than  a  waste  of  your  time  to  enter  into  a 
minute  description  of  all  the  modifications  of  the  respiratory  sounds 
to  which  the  presence  of  tubercle  in  the  lungs  of  children  may  give 
occasion  :  our  time  will  be  better  spent  than  in  such  detail,  if  we  direct 
our  attention  to  those  respects  in  which  the  auscultatory  signs  of 
phthisis  in  childhood  differ  from  those  which  betoken  its  existence  in 
the  adult,  or  in  which  the  same  auscultatory  phenomena  require  a 
different  interpretation  at  the  one  period  of  life,  from  that  which  is 
justly  applied  to  them  at  the  other. 

The  grand  difference,  indeed,  is  to  be  sought  in  the  latter  rather 
than  in  the  former  of  these  respects.  Tubercle,  at  whatever  age  it  is 
developed  in  the  lungs,  gives  rise  to  much  the  same  auscultatory 
phenomena ;  but  many  of  those  modifications  of  the  respiratory  sound 
which  would  warrant  us  in  pronouncing  positively  that  phthisis  existed 
in  the  adult,  cannot  be  relied  on  with  the  same  certainty  in  the  child : 
still  less  can  they  be  regarded  as  proving  the  existence  of  so  large  an 
amount  of  disease  in  the  latter  case  as  in  the  former.  It  may  be 
stated,  then,  that 

1st.  Many  of  the  auscultatory  signs  of  phthisis  deserve  less  reliance,  or 
have  a  less  grave  import,  in  the  child  than  in  the  adult. 

One  of  the  earliest  signs  of  tubercular  deposit  in  the  lungs  of  the 

19 


290 


AUSCULTATORY   SIGNS   OF   PHTHISIS   IN   CHILDREN. 


grown  person  is  furnished  by  that  peculiar  modification  of  the  respira- 
tory sound,  to  which  the  name  of  coarse  breathing  has  been  applied ; 
and  this  acquires  still  greater  importance,  when  associated,  as  it  often 
is,  with  dry-rhonchus  and  creaking  sounds.  Much  of  the  value  of  this 
sign  depends  on  its  being  limited  to  the  infra-clavicular  regions,  or,  at 
least,  heard  there  with  much  greater  distinctness  han  elsewhere  In 
children,  however,  the  deposit  of  tubercle  in  the  lungs  being  more 
uniform,  and  more  generally  diffused,  the  additional  value  which  the 
localization  of  these  signs  furnishes  is  lost ;  and  it  becomes  impossible 
to  determine  whether  the  bronchial  irritation  which  they  betoken  is 
induced  by  the  presence  of  tubercle  in  the  lungs,  or  by  some  other 
cause. 

Prolongation  of  the  expiratory  sound  beneath  the  clavicle,  and  inter- 
rupted respiration, — the  respiration  saccadee  of  French  authors, — 
which  are  two  of  the  earliest  and  most  important  indications  of  phthisis 
in  the  grown  person,  are,  on  the  whole,  of  less  value  in  the  child. 
Their  occurrence,  indeed,  should  always  excite  suspicion  as  to  the 
existence  of  phthisis,  but  they  are  not  infrequently  very  well  marked 
in  cases  where  but  slight  disorder  of  the  respiratory  organs  is  present ; 
and  where  the  perfect  recovery  of  the  child,  and  its  subsequent  sound 
health,  prove  that  tubercular  disease  either  was  altogether  absent  or 
at  any  rate  was  extremely  slight. 

The  exaggeration  of  these  two  signs  is  probably,  in  some  measure, 
due  to  a  cause  which  adds  greatly  to  the  intensity  of  some  other  of  those 
auscultatory  phenomena  that  usually  betoken  far  advanced  phthisis. 
MM.  Rilliet  and  Barthez  were,  I  believe,  the  first  who  pointed  out  the 
fact  that  the  bronchial  glands,  when  enlarged  by  the  deposit  of  tubercle, 
and  thus  brought  into  contact  with  the  walls  of  the  chest,  which  they 
do  not  touch  in  the  healthy  state,  conduct  to  the  ear  of  the  auscultator 
sounds  that  under  other  circumstances  are  inperceptible.  The  air 
passing  through  the  larger  bronchi  is  now  heard,  on  applying  the 
stethoscope  to  the  walls  of  the  chest,  in  the  supra-scapular,  and  less 
often  in  the  infra-clavicular  region,  and  can  scarcely  be  distinguished 
from  bronchial  breathing  produced  by  solidification  of  the  pulmonary 
tissue  itself.  The  sounds  which  are  caused  by  the  presence  of  mucus  in 
the  larger  air-tubes  are  in  the  same  way  conducted  to  the  ear  in  other 
situations  than  those, — such  as  the  root  of  the  lung,  where  alone  they 
would  be  heard  if  the  glands  were  not  enlarged.  The  auscultator  may 
thus  be  betrayed  into  the  error  of  supposing  that  hopeless  phthisis 
exists,  in  cases  where  yet  the  amount  of  disease  in  the  lungs  is  but 
small,  and  where  life  may  be  prolonged  for  many  years.  Morbid 
sounds,  too,  produced  in  one  lung,  may  thus  be  conducted  to  the  walls 
of  the  chest  on  the  opposite  side,  and  the  extent  of  disease  may,  in 
consequence,  be  overrated  ;  or  the  sounds  which,  when  perceived  in  the 
front  of  the  chest,  may  arise  from  real  disease  existing  there,  being 
transmitted  to  the  back  through  the  medium  of  the  glands,  may  thus 
give  rise  to  the  conclusion  that  far  more  serious  mischief  exists  than  is 
really  the  case.  The  means  of  avoiding  error  from  this  cause  consist 
in  the  careful  comparisons  of  the  results  of  auscultation  with  those  of 
percussion,  and  of  those  of  auscultation  on  one  day  with  those  which  it 


PECULIARITIES    OF   THE   AUSCULTATORY   SIGNS   OF  291 

yields  a  few  days  afterwards.  If  the  sounds  proceed  from  solidification 
of  the  lung,  or  from  cavities  in  its  substance,  the  results  of  auscultation 
will  be  as  invariable  as  those  of  percussion  ;  but  if  they  be  merely 
sounds  transmitted  from  the  larger  air-tubes,  they  will  be  found  to  vary 
much  on  different  occasions ;  while  the  dulness  on  percussion  in  certain 
parts  will  continue  unchanged,  inasmuch  as  it  proceeds  from  the 
presence  of  the  enlarged  glands.  This  variability  in  the  results  of 
auscultation  is  one  of  the  most  important  indications  of  bronchial  phthisis. 
It  depends  not  merely  on  the  accidental  variations  in  the  sounds  pro- 
duced in  the  larger  air-tubes,  but  also  on  the  changes  which  the  varying 
degree  of  compression  of  the  bronchi,  produced  by  the  increase  or  dimi- 
nution in  the  size  of  the  glands,  may  occasion,  and  on  the  variations  in 
the  irritation  of  the  air-tubes  which  this  pressure  produces.  The  risk 
in  cases  of  bronchial  phthisis  is  not  so  much  that  of  forming  an  alto- 
gether erroneous  diagnosis,  as  of  expressing  a  prognosis  far  more 
unfavourable  than  the  nature  of  the  case  actually  justifies.  In  cases 
where  a  considerable  measure  of  bronchitis  is  associated  with  tuber- 
culization of  the  glands,  we  are  especially  likely  to  fall  into  this  error, 
and  can  avoid  it  only  by  much  caution,  and  by  frequently  repeated 
auscultation. 

There  are  differences  of  another  kind,  however,  between  the  results 
of  auscultation  in  cases  of  phthisis  in  the  young  and  old,  and  which 
depend 

2d.  On  the  absence,  or  difficult  appreciation,  of  some  auscultatory  'phe- 
nomena in  the  child,  to  which  much  value  is  attached  in  the  case  of 
the  adult\ 

To  this  head  belong  those  differences  which  result  from  the  loss  in 
the  child  of  almost  all  that  information  which,  in  older  persons,  is 
afforded  by  the  different  modifications  of  the  vocal  resonance.  The  shrill 
voice  of  the  child,  the  small  power  of  modulating  it  which  is  possessed 
in  early  life,  and  the  consequent  difficulty  of  inducing  the  patient  to 
utter  a  few  sentences,  or  even  a  few  words,  in  the  same  key,  even  when 
fear  does  not  reduce  the  voice  to  a  mere  whisper,  take  away  almost  all 
value  from  the  modifications  of  the  voice-sound  in  young  subjects. 

The  extreme  excitability  of  children  tends,  as  it  does  also  in  the 
female  subject,  to  reduce  very  low  the  value  of  mere  inequality  of  breath- 
ing between  the  two  lungs ;  for  it  is  by  no  means  a  rare  occurrence  for 
the  lung  which  on  one  day  seemed  to  admit  but  little  air,  to  yield  the 
sounds  of  well-marked  puerile  respiration  on  the  next  day,  and  for  the 
feeble  respiration  to  have  changed  sides.  Before,  therefore,  any  con- 
clusion can  be  drawn  from  the  feebleness  of  the  respiration  in  either 
lung,  its  situation,  degree,  and  extent,  must  be  confirmed  by  repeated 
observation. 

The  finer  variations  in  the  sonoriety  of  the  chest  are  not  so  easily 
distinguished  in  childhood  as  in  more  advanced  age.  The  main  cause 
of  this  appears  to  be  furnished  by  the  extreme  resonance  of  the  chest 
in  early  childhood,  which  will  admit  of  very  considerable  reduction 
before  percussion  elicits  a  sound  that  the  ear  would  recognise  as  at  all 


292  PHTHISIS   IN   CHILDHOOD. 

dull.  Extremely  gentle  percussion  is  much  more  likely  to  elicit  the 
more  delicate  variations  of  sound,  than  those  smart  taps  of  the  chest, 
which,  in  the  grown  person,  will  often  answer  the  purpose  sufficiently 
well. 

A  last  source  of  difference  may  be  mentioned  as  arising 

Zd.  From  the  occurrence  of  some  physical  signs  peculiar  to  the  form 
which  phthisis  assumes  in  early  life. 

The  only  sign  that  comes  with  propriety  under  this  category,  is  that 
dulness  between  the  scapulae  which  is  not  unfrequently  produced  by  the 
presence  of  tuberculous  glands,  and  which,  when  it  coexists  with  tolera- 
ble resonance  over  the  upper  part  of  the  lungs,  and  moderately  good 
respiration  in  these  situations,  may  be  regarded  as  pathognomonic  of 
bronchial  phthisis.  The  absence  of  dulness  in  this  situation,  however, 
does  not  of  itself  warrant  the  inference  that  the  glands  are  free  from 
disease,  but  merely  that  they  have  not  yet  attained  any  very  considerable 
degree  of  enlargement. 

It  may  perhaps  be  useful,  before  we  proceed  to  the  study  of  some 
other  peculiarities  of  phthisis  in  childhood,  briefly  to  recapitulate  the 
general  characteristics  of  the  disease  in  early  life.  The  chief  of  these 
are — 

1st.  The  frequent  latency  of  the  thoracic  symptoms  during  its  early 
stages. 

2d.  That  almost  invariable  absence  of  haemoptysis  at  the  commence- 
ment of  the  disease,  and  its  comparatively  rare  occurrence  during  its 
subsequent  progress. 

3rd.  The  partial  or  complete  absence  of  expectoration. 

4th.  The  rarity  of  profuse  general  sweats;  and  the  ill-marked 
character  of  the  hectic  symptoms. 

5th.  The  frequency  with  which  death  takes  place  from  intercurrent 
bronchitis  or  pneumonia. 

Bronchial  phthisis  is  characterized  by — 

1st.  The  frequent  development  of  its  symptoms  out  of  one  or  more 
attacks  of  bronchitis. 

2d.  The  peculiar  paroxysmal  cough  which  attends  it,  resembling 
that  of  incipient  pertussis. 

3d.  The  great  and  frequent  fluctuations  in  the  patient's  condition, 
and  the  occasional,  apparently  causeless,  aggravation,  both  of  the 
cough  and  dyspnoea. 

In  very  early  infancy,  phthisis  is  remarkable  for  the  very  frequent 
latency  of  the  chest  symptoms,  which,  through  its  entire  course,  are 
often  entirely  merged  in  the  signs  of  impaired  nutrition. 

The  most  important  peculiarities  in  the  auscultatory  phenomena  of 
consumption  in  the  child  are — 

1st.  The  smaller  value  of  coarse  respiration,  prolonged  expiration, 


COURSE   OF   THTHISIS   SOMETIMES   VERY  RAPID.  293 

and  interrupted  breathing,  owing  to  their  general  diffusion  over  the 
chest,  and  to  their  occasional  existence  independent  of  phthisis. 

2d.  The  apparent,  and  to  some  extent  the  real,  exaggeration  of  the 
signs  both  of  early  and  of  far-advanced  disease  of  the  lungs,  in  some 
cases  of  bronchial  phthisis. 

3d.  The  loss  of  that  information  which  the  phenomena  of  the  voice 
furnish  in  the  case  of  the  adult. 

4th.  The  small  value  of  inequality  of  breathing  in  the  two  lungs. 

5th.  The  difficulty  of  detecting  minute  variations  in  the  sonoriety  of 
the  chest;  and 

6th.  The  existence  of  dulness  in  the  interscapular  region,  together 
with  moderate  resonance  of  the  upper  parts  of  the  chest,  and  tolerably 
good  respiration  there,  which  are  characteristic  of  the  presence  of 
enlarged  bronchial  glands. 

Hitherto  we  have  been  occupied  with  the  study  of  the  more  common 
forms  of  phthisis  in  childhood;  but  deviations  are  occasionally  met  with 
from  the  ordinary  course  of  the  disease,  with  which  it  behoves  us  to 
.make  ourselves  acquainted.  Phthisis  occasionally  runs  a  course  so 
extremely  rapid  that  many  of  its  most  characteristic  symptoms  have 
not  time  to  manifest  themselves.  In  such  cases  we  are  exposed  to 
considerable  risk  of  error,  for  the  history  of  the  patient's  indisposition 
goes  back  only  to  a  few  weeks  or  days;  the  evidence  of  impaired 
nutrition  is  almost  or  altogether  wanting,  and  the  symptoms  appear  to 
be  those  of  an  acute  malady  coming  on  suddenly,  rather  than  those  of 
a  slow  and  wasting  disease. 

A  remarkable  instance  of  this  came  under  my  notice  some  years  ago, 
in  the  case  of  a  little  boy,  nine  months  old,  who  was  fat  and  ruddy, 
and  had  always  had  perfectly  good  health  until  the  10th  of  April. 
On  that  day  he  was  taken  with  symptoms  which  his  mother  supposed  to 
be  those  of  a  bad  cold.  On  account  of  this  he  was  kept  in  the  house, 
and  various  domestic  remedies  were  employed,  though  without  any 
improvement,  and  on  April  24th  he  came  under  my  notice.  There  did 
not  then  appear  to  be  any  urgent  symptom,  though  the  child  seemed 
much  oppressed  at  the  chest.  The  case  appeared  to  be  one  of  rather 
severe  catarrh,  occurring  during  the  period  of  dentition.  The  gums 
were  lanced,  and  a  mixture  containing  the  vinum  ipecacuanha  was 
ordered,  to  which,  finding  the  symptoms  did  not  abate,  small  doses  of 
antimonial  wine  were  added  on  the  27th.  On  the  30th  I  was  informed 
that  the  child  was  much  worse,  that  his  dyspnoea  was  greatly  increased, 
and  that  his  hands  and  feet  had  been  swollen  for  the  last  forty-eight 
hours.  I  found  the  little  boy  breathing  fifty  times  in  the  minute,  with 
great  oppression  at  the  chest,  the  face  much  flushed,  the  skin  dry,  the 
trunk  hot,  the  limbs  cool,  and  the  hands  and  feet  much  swollen.  Aus- 
cultation detected  generally  diffused  small  crepitation  through  both 
lungs,  with  indistinct  bronchial  breathing  at  the  upper  and  back  part 
of  the  left  side.  Three  hours  after  this  visit,  the  child  died  without  a 
struggle,  on  being  lifted  out  of  bed  for  his  mother  to  apply  some  leeches 
to  his  chest.  On  examining  the  body  after  death,  a  very  thick  layer 
of  fat  was  found  everywhere  beneath  the  integuments.     The  lungs 


294  ILLUSTRATIVE   CASE — TUBERCULOUS   PNEUMONIA. 

presented  an  extreme  degree  of  tubercular  degeneration,  and  many  of 
the  bronchial  glands  were  enlarged  by  the  morbid  deposit  to  the  size  of 
a  pigeon's  egg.  None  of  the  tubercles  in  the  lungs  were  softened,  but 
it  existed  both  in  the  form  of  yellow  miliary  tubercle,  of  tubercular 
infiltration,  and  of  masses  of  crude  tubercle,  formed  by  the  agglomera- 
tion of  many  separate  deposits.  The  pulmonary  substance  in  the 
intervals  between  the  tubercular  deposits  was  of  a  bright  red  colour,  in 
the  first  stage  of  pneumonia,  and  in  many  parts  bordering  on  the  second 
stage,  and  there  was  very  considerable  injection  of  the  bronchial  tubes. 
The  various  abdominal  viscera  contained  tubercle,  but  it  was  >  not  far 
advanced  in  the  mesenteric  glands. 

This  case  represents  a  class  in  which  there  is  much  hazard  of  forming 
an  erroneous  diagnosis.  It  shows  the  possibility  of  tubercular  deposit 
taking  place  to  a  very  great  extent  without  at  all  interfering  with  the 
general  nutrition  of  the  body,  and  without  giving  rise  to  any  symptom  so 
serious  as  to  attract  the  notice  of  a  very  careful  and  affectionate  mother. 
It  illustrates  also  the  mode  in  which  the  fatal  termination  of  many 
cases  of  phthisis  in  children  is  brought  about,  and  suggests  the  inquiry 
whether  there  be  any  means  of  distinguishing  between  tuberculous  pneu- 
monia, and  pneumonia  which  occurs  uncomplicated  with  phthisical 
disease  of  the  lungs. 

Pneumonia  often  complicates  phthisis  in  early  life,  under  circum- 
stances in  which  no  diagnostic  difficulty  occurs  ;  but  it  is  of  much 
importance  to  detect  the  consumptive  element  in  cases  which  to  the 
superficial  observer  present  no  other  symptoms  than  those  of  acute 
inflammation  of  the  lungs.  The  existence  of  a  considerable  amount  of 
tubercular  deposit  in  the  lungs  may  be  suspected  in  those  cases  in  which 
the  degree  of  oppression  of  the  chest  has,  from  the  very  commence- 
ment of  the  illness,  been  altogether  out  of  proportion  to  the  severity  of 
the  catarrhal  or  bronchitic  symptoms  with  which  the  disease  set  in.  A 
further  evidence  of  its  nature  is  afforded,  if  the  skin,  though  very  dry, 
present  a  less  considerable  or  a  less  pungent  heat  than  attends  simple 
pneumonia,  while  the  pulse  from  the  very  outset  is  less  developed. 
Suspicion  would  be  strengthened  if  the  frequency  of  respiration  very 
greatly  exceeded  the  amount  of  mischief  disclosed  by  auscultation,  and 
especially,  if  the  rapidity  of  the  breathing,  though  so  great  that  it 
would  excite  the  most  serious  alarm  if  the  case  were  one  of  pneumonia, 
should  yet  continue  the  same  for  days  together  without  marked  dete- 
rioration in  the  patient's  condition.  Auscultation  also  would  throw 
much  light  on  the  nature  of  the  case,  for  the  sounds  detected  in  the 
chest  would  be  the  subcrepitant  and  mucous  rales,  rather  than  the  small 
crepitation  of  pneumonia;  while,  though  the  smaller  sounds  would  be 
discovered  at  the  lower  part  of  the  chest,  the  greatest  dulness  on  per- 
cussion would  generally  be  detected  at  the  upper  part,  and  bronchial 
breathing  would  very  likely  be  perceived  more  or  less  distinctly  in  the 
same  situation. 

The  importance  of  distinguishing  those  cases  in  which  inflammation 
supervenes  in  a  lung  already  the  seat  of  tubercular  deposit,  from  others 
in  which  the  organ  had  been  previously  healthy,  is  by  no  means  confined 
to  cases  of  the  severest  kind,  in  which  life  is  immediately  threatened. 


DIFFERENCES  BETWEEN    SIMPLE   AND    TUBERCULOUS   PNEUMONIA.      295 

In  every  instance  of  pneumonia  in  early  life,  both  your  prognosis  and 
your  treatment  would  be  greatly  modified  if  there  were  good  ground  for 
believing  that  tubercular  disease  had  for  some  time  previously  affected 
the  lungs.  Hence  follows  the  necessity  for  that  very  minute  inquiry 
as  to  the  previous  health  of  the  patient,  and  of  the  other  members  of 
the  family,  on  which  so  much  stress  was  laid  at  the  commencement  of 
this  course  of  lectures.  If  you  learned  that  several  children  in  the 
family  had  already  died  of  phthisis  or  of  some  other  affection, — such  as 
acute  hydrocephalus,  which  you  knew  to  be  most  intimately  associated 
with  the  tuberculous  diathesis,  the  possibility  of  the  same  complication 
existing  in  the  patient  under  your  care  would  at  once  occur  to  you. 
This  complication  would  be  rendered  highly  probable,  if  you  were  to 
ascertain  that  the  child  had  been  peculiarly  liable  to  catch  cold,  or  had 
for  some  months  been  seldom  free  from  cough  for  many  days  together, 
or  had  suffered  from  cough  every  winter,  for  two  or  three  years,  and 
had  already  experienced  two  or  three  attacks  similar  to  that  you  are 
called  on  to  treat,  and  which,  though  severe,  had  yet  subsided  by 
degrees,  without  the  employment  of  very  active  measures.  The  proba- 
bility would  be  raised  almost  to  certainty  if  there  existed  that  want  of 
correspondence  between  the  general  symptoms  and  physical  signs,  or 
between  the  results  of  auscultation  and  percussion,  to  which  reference 
has  already  been  made  ;  or  if  the  history  of  the  present  illness  went 
back  to  a  period  anterior  to  that  which  you  would  be  disposed  to 
assign  to  it,  if  the  affection  had  been  simple  pneumonia. 

The  case  of  tuberculous  pneumonia  you  would  deplete  more  spar- 
ingly, and  would  subject  to  less  rigorous  antiphlogistic  measures  than 
that  of  simple  inflammation  of  the  lung.  Bearing  in  mind  the  influence 
of  enlarged  bronchial  glands  in  rendering  parts  of  the  chest  dull  on 
percussion,  and  in  exaggerating  in  some  respects  the  morbid  sounds, 
you  would  not  over-estimate  the  degree  or  extent  of  the  inflammatory 
mischief.  At  the  same  time  you  would  not  allow  even  a  considerable 
measure  of  improvement  to  lead  you  to  speak  too  decidedly  of  the 
ultimate  recovery  of  your  patient;  since  you  would  not  forget  that,  if 
inflammation  do  not  originate  tuberculous  disease,  it  may  yet  communi- 
cate increased  activity  to  its  progress. 

The  overlooking  the  more  serious  malady,  owing  to  its  symptoms 
being  thrown  into  the  shade  by  those  of  the  other  more  curable  affec- 
tion, is  not  the  only  error  to  which  you  are  exposed  in  cases  of  infan- 
tile phthisis.  The  degree  of  irritation  of  the  bronchi  that  exists  in 
different  instances,  varies  exceedingly;  sometimes  it  is  so  considerable, 
that  when  the  child  is  placed  under  your  care  its  respiration  is  wheez- 
ing, difficult,  and  very  hurried,  its  cough  violent  and  exhausting;  while 
such  is  the  general  anxiety  of  the  countenance,  and  so  great  is  the  de- 
pression of  the  vital  powers,  that  the  struggle  seems  as  if  it  could  not 
be  long  protracted.  Percussion  detects  dulness  at  the  upper  part  of 
the  chest ;  the  bronchi  are  so  laden  with  phlegm,  that  air  scarcely 
penetrates  beyond  the  larger  tubes,  and  mucous  rale  is  heard  through- 
out the  whole  of  the  lungs,  while  at  their  upper  part  it  is  so  large  as  to 
amount  almost  to  gurgling.  You  regrrd  the  case  as  one  of  far  ad- 
vanced phthisis,  and  suppose  that  softened  tubercle  is  diffused  through 


296      COMPLICATION   WITH  BRONCHITIS   EXAGGERATES  THE   SYMPTOMS. 

the  whole  of  both  lungs,  and  that  cavities  exist  at  their  apex.  You  form 
the  most  gloomy  prognosis,  and  entertain,  very  probably  express  the 
conviction,  that  a  few  weeks  at  furthest  will  be  the  period  of  your 
patient's  life.  By  degrees,  however,  the  most  urgent  symptoms  sub- 
side, and  some  signs  of  returning  health  appear;  the  respiration  grows 
slower  and  more  tranquil,  the  cough  abates,  perhaps  almost  ceases. 
The  signs  of  a  cavity  grow  less  and  less  distinct,  in  proportion  as  the 
secretion  in  the  bronchi  diminishes ;  and  after  some  months,  while  the 
patient's  general  condition  deviates  but  little  from  a  state  of  health,  a 
little  dulness  at  the  upper  and  back  part  of  the  chest,  unequal  breath- 
ing, prolonged  expiration,  or  morbid  sounds  equally  slight,  are  the  only 
auscultatory  evidence  that  the  most  careful  examination  can  discover 
of  pulmonary  disease. 

Non-professional  persons  are  apt  to  imagine  the  mistake  in  cases  of 
this  kind  to  have  been  greater  than  it  really  was.  The  error  is  one  as 
to  the  degree  of  the  malady,  rather  than  as  to  its  kind.  In  cases  that 
present  these  symptoms,  phthisis  has  in  reality  existed,  but  the  chief 
tubercular  deposit  has  probably  been  seated  in  the  bronchial  glands, 
and  their  enlargement  gave  rise  to  much  of  the  dulness  on  percussion, 
and  exaggerated  the  morbid  sounds  at  the  upper  part  of  the  chest. 
Erom  some  accidental  cause,  such  as  cold  or  damp,  or  from  the  mucous 
membrane  of  the  bronchi  sympathizing  with  disorder  of  the  digestive 
organs,  or  from  inappropriate  treatment  which  aggravated  the  evil  it 
should  have  relieved,  or  even  without  any  cause  that  we  can  assign,  it 
had  come  to  pass  that  the  air-tubes  were  in  a  state  of  great  irritation. 
The  due  regulation  of  temperature,  generally  appropriate  treatment, 
and  nature's  own  healing  power,  improved  the  general  health  and 
diminished  the  irritability  of  the  bronchi ;  while  very  probably  the  dis- 
eased glands  emptied  themselves,  at  least  in  part,  into  the  air-tubes, 
and  the  tubercle  was  thus  eliminated  from  the  system.  You  should, 
therefore,  always  express  your  opinion  very  guardedly  with  reference 
to  the  condition  of  a  child  suffering  from  phthisis,  until  you  have  con- 
firmed the  results  of  auscultation  by  its  frequent  repetition,  and  till  you 
have  had  the  opportunity  of  determining  how  large  a  portion  of  the 
physical  signs  is  due  to  the  morbid  deposit,  and  how  much  to  that  irri- 
tation of  the  bronchi  which  you  may  fairly  hope  to  mitigate,  if  not  to 
remove. 

The  average  duration  of  phthisis  in  childhood,  is  estimated  by  MM. 
Rilliet  and  Barthez  at  from  three  to  seven  months,  though,  as  they 
justly  observe,  its  extreme  limits  vary  from  two  months  in  unusually 
rapid  cases,  to  two  years  and  upwards  in  other  instances,  in  which  the 
course  of  the  disease  is  very  protracted.  It  is  my  impression,  indeed, 
that  the  ordinary  duration  of  phthisis  in  childhood  is  less  brief  than  the 
observations  of  these  gentlemen,  made  among  the  children  in  the 
Hopital  des  Enfans  at  Paris,  have  led  them  to  believe ;  though  the 
number  of  observations  on  which  this  impression  rests  is  too  limited  to 
warrant  my  asserting  it  as  a  positive  fact.  Many  cases,  however,  have 
come  under  my  notice  in  which  the  course  of  well-marked  phthisis  has 
been  extremely  tardy,  and  some  instances  in  which  the  disease  has 
continued  for  two,  three,  four,  and  nearly  five  years,  before  it  termi- 
nated fatally. 


CHRONIC  PHTHISIS.  297 

So  little  notice  has  been  taken  of  this  chronic  form  of  phthisis  in 
children,  that  it  may  be  "well  to  relate  a  few  examples  of  it.  In  March, 
1842,  I  saw  a  little  girl,  six  years  old,  whose  father  had  died  of  phthisis, 
and  who  had  had  a  cough  ever  since  she  suffered  from  measles  two  and 
a  half  years  before.  Her  mother's  anxiety  had  been  excited  by  the 
increase  of  this  cough,  and  by  the  child's  losing  flesh  during  the  few 
weeks  previous  to  her  coming  to  me.  Auscultation  at  this  time  disco- 
vered that  air  entered  the  lung  in  the  left  infra-clavicular  region  more 
scantily  than  in  the  right,  and  that  the  respiration  was  coarse,  and 
attended  with  much  creaking  at  the  upper  part  of  both  lungs.  In  May, 
the  general  symptoms  were  much  improved,  and  the  creaking  sounds 
were  no  longer  heard.  For  many  months  the  child  continued  to  appear 
tolerably  well,  though  her  cough  never  ceased  entirely ;  but  in  the 
early  part  of  the  winter  of  1844  her  health  completely  failed.  Exami- 
nation of  the  chest  in  the  beginning  of  December  elicited  great  defi- 
ciency of  resonance  at  the  upper  part  of  the  left  lung,  both  in  front 
and  behind.  Bronchial  breathing,  intermixed  with  large  mucous  rale, 
was  heard  in  the  left  supra-scapular  region,  and  abundant  moist  sounds 
pervaded  the  lung  posteriorly.  In  the  left  infra-clavicular  and  mam- 
mary regions  the  respiration  was  very  deficient,  and  accompanied  with 
distant  moist  sounds.  Extreme  coarseness  of  the  respiration  was  the 
only  morbid  sound  heard  at  the  upper  part  of  the  right  lung,  and  the 
breathing  on  that  side  was  puerile  in  other  parts.  In  January,  1845, 
the  child  had  slight  hsemoptysis,  which  recurred  occasionally  at  intervals 
of  a  few  weeks  or  months  until  her  death,  but  was  not  profuse  at  any 
time.  In  September,  1845,  resonance  was  slightly  impaired  under  the 
right  clavicle,;  and  also  in  a  greater  degree  posteriorly,  as  far  as  the 
angle  of  the  scapula. '  There  was  absolute  dulness  of  the  left  side,  as 
far  as  the  nipple  in  front,  and  the  angle  of  the  scapula  behind.  There 
was  no  natural  breathing  in  the  left  lung,  but  the  respiration  was  bron- 
chial, and  accompanied  with  large  mucous  rale  as  low  as  the  nipple ; 
the  rale  being  smaller,  and  the  admission  of  air  scanty,  below  that 
point.  About  the  left  scapula  there  were  cavernous  sounds  and  distinct 
gurgling,  smaller  moist  sounds  lower  down.  In  the  right  lung  the 
respiration  was  puerile  in  front,  except  quite  at  the  upper  part,  where 
the  breathing  was  coarse,  and  attended  with  mucous  rale ;  and  poste- 
riorly the  same  characters  were  still  more  marked. 

It  cannot  be  necessary  to  detail  the  results  of  the  subsequent  exami- 
nations of  the  chest,  which  showed  that  disease  advanced  slowly  in  the 
right  lung,  though  there  was  at  no  time  proof  of  the  existence  of  a 
cavity  there.  The  child's  condition  fluctuated  :  sometimes  she  seemed 
almost  dying  under  an  aggravation  of  all  the  symptoms,  and  then  again 
she  rallied,  and  was  able  to  walk  about,  and  seemed  tolerably  comforta- 
ble. Life  was  prolonged  until  June  1st,  1847 ;  and  she  had  seemed 
almost  as  well  as  usual  until  a  very  few  days  before  her  death. 
Unfortunately,  permission  to  examine  the  body  could  not  be  obtained ; 
but  the  stethoscopic  signs  enable  us  to  trace  back  the  phthisical  disease 
for  more  than  five  years,  while  the  evidence  of  a  large  cavity  in  the 
left  lung  was  distinct  twenty-one  months  before  death  took  place. 

Nor  is  this  a  solitary  case.     In  January,  1846,  I  saw  a  little  boy, 


298  CASES   IN   ILLUSTRATION. 

three  years  old,  who  had  had  cough  ever  since  an  attack  of  typhoid 
fever  in  the  previous  July ;  and  for  six  weeks  before  he  came  under  my 
notice  his  cough  had  grown  more  severe.  There  was  then  very  marked 
flattening  of  the  left  side  of  the  chest,  which  yielded  a  dull  sound  on 
percussion  in  the  infra-clavicular  and  mammary  regions;  and  air 
entered  there  very  scantily.  The  same  dulness  existed  on  the  left  side 
posteriorly ;  and  the  scanty  breathing  was  attended  with  a  crumpling 
sound.  In  April,  moist  sounds  wrere  evident  there  ;  and  in  May  they 
wTere  becoming  larger  about  the  left  scapula ;  and  signs  of  incipient 
disease  were  now  perceptible  in  the  right  lung.  In  September,  there 
was  absolute  dulness  in  the  left  infra-clavicular  region,  slightly  dimin- 
ishing towards  the  nipple,  and  absolute  dulness  in  the  left  scapular 
region.  Large  gurgling  was  heard  in  this  situation,  most  marked 
behind,  and  rendered  very  striking  during  a  fit  of  coughing,  which  wras 
followed  by  expectoration  of  about  a  teaspoonful  of  pus.  From  this 
time  to  the  present  he  has  continued  nearly  stationary.  The  child  is 
considerably  stouter  than  he  was  when  he  first  came  under  my  notice ; 
but  the  cough  and  purulent  expectoration  continue.  I  auscultated  his 
chest  on  Sept.  26,  1847,  and  at  that  time  loud  blowing  respiration  was 
heard  over  the  whole  of  the  left  scapula,  accompanied  with  gurgling  ; 
while,  lower  down,  there  were  large  moist  sounds,  though  not  amounting 
to  actual  gurgling.  From  that  time  until  August  1848,  the  child's 
health  continued  tolerably  good ;  he  coughed  but  little,  but  suffered 
from  occasional  attacks  of  diarrhoea.  The  left  side  of  his  chest  was 
much  shrunken,  and  yielded  a  dull  sound  every  where  except  just  under 
the  clavicle.  Air  entered  but  scantily  ;  moist  sounds  attended  it,  but 
the  evidences  of  a  large  cavity  were  growing  less  and  less  distinct.  In 
June  1849,  I  saw  him  for  the  last  time ;  the  amount  of  air  entering  the 
left  lung  was  not  increased,  but  the  moist  sounds  had  almost  completely 
disappeared. 

How  long  the  disease  may  continue,  or  what  may  be  the  ultimate 
issue  of  the  case,  it  would  be  useless  to  speculate  on ;  though  it  is  by  no 
means  unlikely  that  the  child  may  live,  with  but  little  deterioration  in 
his  condition,  until  measles  or  hooping-cough  imparts  a  fresh  stimulus 
to  the  consumptive  disease,  or  excites  some  fatal  attack  of  bronchitis  or 
pneumonia.  I  used  to  see  occasionally  a  little  boy,  who  was  aged  only 
three  years  when  he  first  came  under  my  notice,  and  whom  1  had  the 
opportunity  of  watching  till  he  was  eleven  years  old.  When  first  brought 
to  me  he  had  been  suffering  from  cough  ever  since  an  attack  of  what 
his  mother  called  inflammation  of  the  lungs,  when  he  was  sixteen 
months  old:  his  cervical  glands  had  recently  suppurated;  he  had 
unusually  well-marked  hectic  fever,  and  profuse  night  sweats ;  and  a 
month  before  I  saw  him  had  spat  blood  once.  His  right  side  yielded 
throughout  a  dull  sound  on  percussion :  breathing  in  that  lung  was 
scanty,  and  attended  with  large  moist  sounds.  The  child  went  into 
Devonshire  to  pass  the  winter,  and,  as  I  expected,  to  die  there  of 
phthisis  ;  but  he  returned  in  better  health ;  he  grew  tall,  and  played 
about  like  other  children,  though  he  seldom  passed  more  than  a  few 
months  without  attacks  of  a  pleuritic  character,  the  pain  of  which  he 
used  to  refer  to  his  right  side,  and  which  usually  subsided  in  the  course 


CASE  OF  CHRONIC  PHTHISIS.  299 

of  a  few  days,  without  any  treatment  more  severe  than  a  mustard 
poultice,  and  some  diaphoretic  medicine.  His  cough  never  left  him 
entirely ;  but  both  that  and  the  quantity  and  character  of  his  expecto- 
ration varied,  and  sometimes  he  spat  a  little  blood.  In  October,  1844, 
the  auscultatory  signs  were  as  follows  : — The  left  lung  yielded,  as  it  had 
constantly  done,  the  sounds  of  puerile  breathing  in  front ;  posteriorly, 
the  breathing  in  that  lung  was  also  good,  except  that  there  were  some 
moist  sounds  in  the  infra-scapular  region,  and  that  the  breathing  had 
a  coarse  and  almost  tubular  character  about  the  upper  angle  of  the 
scapula.  In  the  right  lung,  in  front,  the  respiration  was  puerile,  with 
now  and  then  a  little  distant  crepitus,  as  low  clown  as  the  lower  edge  of 
the  second  rib,  at  which  point  the  moist  sounds  became  larger.  Pos- 
teriorly there  were  large  moist  sounds,  intermixed  with  puerile  breathing 
in  the  supra-scapular  region ;  gurgling,  cavernous  breathing,  and 
bronchial  voice  about  the  scapula;  and  lower  down  there  was  very  little 
respiration,  and  that  of  a  bronchial  character,  becoming  quite  inaudible 
in  the  lateral  region.  In  the  axillary  region  the  respiration  was  coarse, 
accompanied  with  large  mucous  rales.  In  March,  1849,  I  saw  him  for 
the  last  time.  He  had  then  continued  for  more  than  eighteen  months 
free  from  any  serious  pleuritic  attack,  and  from  haemoptysis.  His 
respiration  was  still  hurried,  but  he  had  gained  flesh,  and  sometimes 
walked  five  or  six  miles  in  a  day  without  inconvenience.  Auscultation 
showed,  too,  that  his  disease  had  been  stationary  for  the  previous  five 
years, — if,  indeed,  it  had  not  actually  improved.  The  moist  sounds 
about  the  left  scapula  were  smaller,  and  heard  over  a  smaller  surface. 
The  indications  of  a  cavity  in  the  back  part  of  the  right  lung  continued 
unchanged,  but  not  increased  ;  while  in  other  respects  auscultation  gave 
exactly  the  same  results  as  before.  Other  cases  of  a  similar  kind  have 
come  under  my  observation,  in  which  the  history  of  phthisis  went  back 
for  several  years,  and  in  which  the  signs  of  caverns  in  the  lungs  were 
unmistakable ;  the  children  continuing  to  lead  a  sort  of  valetudinarian 
existence,  improving  in  health,  and  gaining  flesh  and  strength  in  the 
summer,  but  losing  ground  again  with  the  return  of  winter. 

In  the  present  condition  of  our  knowledge,  it  is  not  possible  to  state 
with  certainty  either  the  anatomical  characters  of  phthisical  cavities  of 
long  standing,  or  the  signs  which,  during  the  patient's  life-time,  would 
warrant  the  expectation  that  the  disease  will  run  a  tardy  course;  but 
it  is  well  to  bear  in  mind,  that  such  cases  are  by  no  means  very  rare ; 
that  the  powers  of  repair  are  far  greater  in  the  child  than  in  the  adult. 
We  must  now,  therefore,  pass  on  to  notice  briefly  the  treatment  of  the 
disease,  after  glancing  for  a  moment  at  the  different  modes  in  which  it 
brings  about  a  fatal  issue. 

In  a  very  large  proportion  of  cases  of  phthisis,  the  functions  of  all 
the  organs  of  the  body  become  at  length  so  much  disturbed,  and  nutri- 
tion generally  so  impaired,  that  the  patient  dies,  because  the  whole 
machine  is  worn  out.  But  though  this  is  the  case  in  many  instances, 
yet  it  often  happens,  even  when  the  powers  have  long  seemed  nearly 
exhausted,  and  the  body  is  wasted  almost  to  a  skeleton,  that  death  is 
far  from  tranquil,  but  is  preceded  by  hours  of  severe  agony,  for  which 
it  is  not  easy  to  account.     In  many  cases,  and  especially  in  those  where 


300  MODES  OF  DEATH  IN  PHTHISIS. 

the  disease  runs  a  rapid  course,  the  fatal  termination  is  due  to  an 
attack  of  intercurrent  bronchitis  or  pneumonia,  which  is  sometimes 
supposed  to  have  been  the  patient's  only  disease,  until  a  post-mortem 
examination  reveals  the  tubercular  degeneration  of  the  lungs,  to  which 
the  inflammatory  affection  was  but  secondary.  Death  from  haemoptysis 
is  rare,  and  still  rarer  is  the  perforation  of  the  lung,  by  the  walls  of 
the  cavity  giving  way  at  some  point,  and  thus  producing  pneumothorax. 
The  abdominal  symptoms  sometimes  mask  the  thoracic,  and  the  patient 
dies  of  tuberculous  peritonitis,  who,  had  life  been  prolonged,  would 
have  sunk  eventually  under  pulmonary  phthisis.  Many  children,  in 
whom  the  signs  of  incipient  phthisis  have  appeared,  die  of  acute  hydro- 
cephalus, excited  by  the  membranes  of  the  brain  having  become  the 
seat  of  tubercular  deposit ;  and  some,  in  whom  the  disease  has  attained 
a  more  advanced  stage,  are  suddenly  carried  off  by  head  symptoms,  the 
cause  of  which  is  explained  by  the  discovery  of  large  masses  of  tubercle 
in  the  cerebral  substance.  Convulsions,  however,  sometimes  precede 
death  for  several  hours,  or  head  symptoms  of  greater  or  less  intensity 
constitute  the  most  striking  feature  in  the  patient's  history  for  some 
days  before  death  takes  place;  and  yet,  an  examination  of  the  body 
throws  no  light  upon  the  cause  of  their  occurrence.  Sometimes,  too, 
the  symptoms  that  precede  death  are  those  of  fever  of  a  typhoid 
character,  rather  than  of  serious  mischief  in  the  chest.  They  were  so 
in  the  case  of  a  little  boy,  nearly  seven  years  old  at  death,  who  had 
shown  the  symptoms  of  phthisis  for  more  than  two  years,  and  the  right 
side  of  whose  chest  had  during  that  time  presented  the  indications  of 
gradually  increasing  tubercular  deposit.  The  disease  had  advanced 
slowly,  and  with  long  intermissions,  though,  on  the  whole,  very  mani- 
festly increasing.  On  Nov.  8  there  was  a  manifest  aggravation  of  his 
chest  symptoms,  attended  with  much  fever.  On  the  night  of  the  12th 
his  mind  wandered,  and,  when  sensible,  he  complained  of  his  head.  On 
the  14th  he  became  delirious  likewise  during  the  day ;  and  until  his 
death,  which  did  not  take  place  before  Dec.  1,  his  mind  wandered 
during  many  hours  of  every  day,  while  at  night  he  was  quite  light- 
headed, extremely  restless,  and  tried  to  get  out  of  bed,  or  at  other 
times  shrieked  loudly,  as  if  in  violent  pain.  In  the  early  part  of  his 
illness  he  had  a  frequent,  short,  cough,  which  subsided  as  the  febrile 
symptoms  increased  in  intensity ;  but  his  respiration  throughout  con- 
tinued at  about  50  in  the  minute ;  and  this  hurried  breathing,  coupled 
with  the  auscultatory  signs,  afforded  the  only  evidence  of  the  mischief 
that  was  going  on  within  the  chest.  After  death  the  only  morbid 
appearance  of  any  importance  was  discovered  in  the  upper  lobe  of  the 
right  lung.  Its  anterior  fourth  was  perfectly  solid  and  non-crepitant, 
of  a  yellowish  red  colour,  owing  to  the  infiltration  of  tubercle  into  it. 
Its  posterior  three-fourths  were  of  a  reddish  colour,  and  of  a  much 
softer  texture:  while  the  slightest  pressure  with  the  finger  reduced 
their  substance  to  a  putrilage,  from  which  there  flowed  a  dirty  reddish 
liquid,  which  seemed  like  a  mixture  of  blood,  and  pus,  and  serum. 
Inflammatory  softening  of  this  lobe  seems  to  have  been  the  cause  of 
death,  though  manifesting  itself  less  by  local  symptoms  than  by  the 
signs  of  most  serious  constitutional  disturbance. 


PROPHYLACTIC  TREATMENT   OF   PHTHISIS.  301 

Though  the  study  of  phthisis,  in  its  effects  and  its  symptoms,  has 
occupied  us  during  almost  the  whole  of  two  lectures,  yet  there  need  be 
but  little  said  with  reference  to  its  treatment.  The  main  principles  by 
which  we  are  to  be  guided  in  its  treatment  are  the  same  at  every  age; 
nor  do  the  differences  in  the  patient's  years  bring  with  them  many  or 
important  modifications  in  the  means  by  which  these  principles  are  to 
be  carried  into  action. 

Among  the  prophylactic  measures  adapted  to  early  life,  none  is  of 
more  importance  than  the  keeping  the  infant  at  the  breast  for  the  first 
twelve  or  eighteen  months  of  its  existence,  by  which  time  it  will  have 
passed  through  some  at  least  of  the  dangers  incidental  to  the  period  of 
teething.  The  task  of  thus  nursing  the  infant,  however,  ought  not  to 
be  undertaken  by  a  mother  who  has  shewn  any  tendency  to  consump- 
tion, or  in  whose  family  consumptive  disease  has  been  prevalent,  but 
ought  at  once  to  be  entrusted  to  a  healthy  wet-nurse.  This  rule  does 
not  rest  on  mere  theoretical  grounds  ;  but  actual  observation  has  shown 
that  under  some  morbid  states  of  the  system  the  milk  undergoes  great 
changes,  and  loses  much  of  its  nutritive  properties.  In  the  case  of  the 
cow,  these  changes  have  been  ascertained  by  Dr.  Klencke  of  Leipzic  to 
be  very  remarkable  ;  and  analogical  reasoning  would  warrant  the  belief 
that  the  scrofulous  taint  in  the  human  subject  may  give  rise  to  altera- 
tions of  a  similar  kind.  Dr.  Klencke  confirmed  the  observation  of 
Dr.  Carswell  and  others,  that  stall-fed  cows  are  very  liable  to  become 
tuberculous  ;  and  found,  moreover,  that  under  those  circumstances  their 
milk  loses  much  or  the  whole  of  its  sugar ;  that  the  butter  and  casein 
diminish,  while  albumen  is  found  sometimes  in  as  high  a  proportion  as 
15  per  cent.^and  elain  in  the  proportion  of  1-4  per  cent.,  and  that  in 
some  cases  lactic  acid  is  likewise  present.  Even  if  we  set  aside  the 
assumption  of  scrofulous  disease  being  actually  transmitted  through 
the  medium  of  the  milk,  of  which  there  is  perhaps  no  clear  evidence, 
it  is  yet  apparent  that  a  very  slight  degree  of  such  an  alteration  in  its 
constituents  as  has  just  been  mentioned  must  render  it  very  unfit  for 
the  nutriment  of  a  delicate  infant.  / 

It  is  needless  to  dwell  here  on  the  general  rules  for  feeding  and 
clothing  children  as  they  grow  older,  or  to  insist  on  the  necessity  for 
the  bed-rooms  being  airy  and  well  ventilated.  When  the  damp  and  cold 
weather  of  winter  approaches,  removal  to  a  warmer  climate,  in  which 
exercise  in  the  open  air  may  still  be  continued,  is  much  to  be  preferred 
to  keeping  the  child  for  weeks  together  a  prisoner  to  the  house  ;  and  as 
a  general  rule  more  is  gained  by  change  of  climate  in  early  life  than  in 
adult  age.  In  children  who  are  old  enough  to  be  taught  to  wear  it,  I 
have  sometimes  seen  the  respirator  of  much  service,  in  enabling  them 
to  continue  to  take  exercise  in  the  open  air  at  a  season  when,  on  pre- 
vious years,  exposure  to  the  external  air  had  always  induced  or  greatly 
aggravated  the  signs  of  bronchial  irritation.  Whenever  catarrhal 
symptoms  appear,  no  care  can  be  too  great  to  bestow  on  the  attempt 
speedily  to  remove  them.     In  doing  so,  however,  and  in  the  manage- 

1  Ueber  die  Ansteckung  und  Verbreitung  der  crofelkrankeit  bei  Menschen  durch  den 
Genuss  der  Kuhmilch,  ltimo.     Leipzig,  1846. 


302  TREATMENT   OF   PHTHISIS. 

ment  of  all  ailments  that  come  on  in  children  who  have  shown  a  dispo- 
tion  to  consumptive  disease,  much  caution  must  be  used,  in  order  to 
avoid  over-treating  them.  On  this  account  it  is  of  extreme  importance 
to  encounter  them  at  their  very  commencement,  when  mild  measures 
will  suffice  for  their  cure ;  and,  for  the  same  reason,  the  child  should 
be  defended  with  the  most  punctilious  care  from  the  contagion  of  hoop- 
ing-cough and  of  the  eruptive  fevers — diseases  in  the  course  of  which 
serious  thoracic  complications  are  so  apt  to  supervene,  and  to  require 
for  their  cure  most  active  treatment. 

In  carrying  out  this  plan  of  unwearied  watchfulness,  and  of  attention 
to  minute  detail  continued  for  months  and  years,  you  will  have  brighter 
hopes  with  children  for  your  patients,  than  if  you  were  called  on  to 
exercise  similar  precautions  in  the  case  of  persons  more  advanced  in 
life.  Without  raising  baseless  expectations,  too,  you  may  communicate 
something  of  hope  to  the  parents,  and  thus  lighten  for  them  their 
anxious  task  ;  nor  will  the  appearance  even  of  decided  physical  signs 
of  tubercular  deposit,  nor  the  evidence  that  in  some  parts  that  tubercle 
is  softened,  warrant  an  absolutely  hopeless  prognosis.  Cases  such  as 
have  been  related  show  how  long  life  may  be  prolonged  under  circum- 
stances the  most  inauspicious  ;  and,  where  speedy  death  has  been 
expected,  an  unlimited  reprieve  seems  almost  a  pardon. 

^  It  may  suffice  to  have  said  thus  much  about  the  management  of 
phthisis  in  childhood ;  for  when  the  disease  is  actually  developed,  we 
have  the  same  indications  as  in  the  adult,  and  these  must  be  met  by 
similar  means.  Iron,  quinine,  and  the  mineral  acids,  are  the  most 
important  of  our  tonic  remedies  ;  and  for  these  the  extract  of  bark  and 
the  extract  of  logwood  may  be  substituted,  if  much  tendency  exist  to  a 
relaxed  state  of  the  bowels.  In  cases  where  the  glands  of  the  neck  are 
affected,  and  where  there  seems  to  be  reason  for  supposing  that  the 
disease  approximates  to  bronchial  phthisis,  the  syrup  of  the  iodide  of 
iron  may  be  employed  with  advantage.  Such  cases,  too,  have  seemed  to 
me  to  profit  most  by  the  cod-liver  oil,  though  I  must  confess  that  my 
own  experience  of  it  does  not  altogether  bear  out  the  high  encomiums 
which  have  been  bestowed  upon  it  by  some  practitioners.  Sometimes  I 
have  known  it  excite  diarrhoea ;  at  other  times  it  completely  spoils  the 
appetite ;  while,  as  a  general  rule,  I  think  it  is  not  borne  well  in  cases 
where  dyspeptic  symptoms  are,  as  is  so  often  the  case,  at  all  a  prominent 
feature  in  the  disease.  Sometimes,  too,  the  child's  repugnance  to  the 
remedy  is  unconquerable,  though  this  does  not  often  occur.  If  given  on 
a  little  orange  wine,  or  orange  juice,  sweetened  with  syrup  of  orange 
peel  if  necessary,  its  taste  is  in  general  perfectly  disguised  ;  while  some- 
times, nauseous  though  the  oil  is,  children  become  really  fond  of  its 
flavour.     The  sickness  and  the  paroxysmal  cough  are  best  relieved  by 

'  the  hydrocyanic  acid,  with  which  the  liquor  cinchona  of  Mr.  Battley 
may  be  combined,1  in  cases  where  we  are  afraid  to  venture  on  any  but 
the  mildest  tonics.  Among  local  measures,  the  use  of  stimulating  lini- 
ments to  the  chest  are  even  more  valuable  in  early  life  than  in  the  adult ; 
and  sometimes  the  application  of  a  blister  about  the  size  of  a  shilling, 

i  Sec  Formula,  No.  20,  p.  277. 


DISEASES   OF   THE   HEART.  303 

under  one  or  other  clavicle,  and  its  frequent  repetition,  are  followed  by 
a  very  great  amendment  in  the  patient's  condition,  and  by  a  marked 
improvement  in  the  physical  signs  furnished  by  the  subjacent  lung. 

I  have  very  rarely  employed  local  depletion,  except  in  the  treatment 
of  the  pneumonia  which  so  often  attacks  the  phthisical  patient ;  but  it 
has  then  seemed  sometimes  to  be  of  great  service;  and  it  will  probably 
be  safer  to  trust  to  a  moderate  abstraction  of  blood  by  leeches,  followed 
by  smaller  doses  of  antimonials,  than  to  administer  mercury,  or  to  give 
antimony  in  larger  doses  without  previous  depletion.  The  habitual 
cough  of  phthisis  requires  small  doses  of  ipecacuanha  wine,  combined 
or  not  with  antimony,  and  laudanum,  or  compound  tincture  of  camphor, 
in  small  doses — remedies  which,  on  account  of  their  strength  being  defi- 
nite, are  always  to  be  preferred,  in  the  management  of  the  affections  of 
childhood,  to  a  preparation  so  variable  as  the  syrup  of  poppies.  Opiates 
in  various  forms,  and  for  various  purposes,  may  be  needed  to  check 
diarrhoea,  or  to  relieve  suffering  ;  and  you  must  not  allow  any  precon- 
ceived notion  of  the  danger  of  employing  opium  in  infantile  diseases  to 
prevent  your  having  recourse  to  so  valuable  a  medicine. 

We  must  here  leave  this  subject,  so  full  of  painful  interest,  and 
proceed  at  our  next  lecture  to  the  study  of  diseases  of  the  heart  in  early 


LECTURE    XXVI. 

Diseases  op  the  Heart — reasons  why  much  rarer  in  childhood  than  in  the  adult — but 
often  overlooked  when  present— Rarity  probably  exaggerated,  as  stiown  by  table — 
rheumatic  inflammation  their  most  frequent  cause — rheart  sometimes  affected  when 
rheumatic  symptoms  are  very  slight — both  endocarditis  and  pericarditis  may  come  on 
independently  of  rheumatism — as  sequelas  of  scarlatina — as  complications  of  pleurisy 
— or  as  purely  idiopathic  affections — illustrative  cases. 

Idiopathic  endocarditis  sometimes  attended  by  very  few  symptoms — importance  of  its 
early  detection — tendency  of  valvular  disease  to  grow  worse  and  worse — power  of  the 
growing  heart  to  ward  off  the  effects  of  disease — great  rarity  of  anaemic  bruits  in 
early  life. 

Congenital  affections  of  the  heart — reasons  for  not  studying  them  here  in  detail— cases 
illustrative  of  some  of  their  symptoms. 

Among  the  many  causes  of  suffering  and  death  to  which  persons  in 
adult  or  advancing  years  are  exposed,  diseases  of  the  heart  and  great 
vessels  occupy  a  very  prominent  place.  The  frequency  of  these  affec- 
tions is,  indeed,  but  very  imperfectly  shewn  by  our  tables  of  mortality, 
which  represent  them  as  occasioning  less  than  one  and  a  half  percent,  of 
the  total  deaths  at  all  ages  in  the  metropolis ;  but  we  know  that  in  a 
large  proportion  of  cases  of  rheumatism,  asthma,  bronchitis,  and  dropsy, 
the  real  cause  of  the  fatal  event  is  to  be  found  in  the  cardiac  mischief 
with  which  those  maladies  are  so  often  associated. 

In  childhood,  however,  many  of  the  most  influential  causes  of  heart 
disease  are  of  comparatively  rare  occurrence  ;  rheumatism  is  popularly 
regarded  as  an  affection  almost  confined  to  youth  and  early  manhood,  as 


304:  DISEASES   OF   THE   HEART — ACUTE  RHEUMATISM. 

granular  degeneration  of  the  kidneys  is  to  adult  and  declining  age ; 
while' all  those  forms  of  atheromatous  deposit  in  the  coats  of  arteries, 
or  in  the  substance  of  the  valves  of  the  heart,  which  are  a  fertile  source 
of  suffering,  and  in  their  consequences  a  frequent  cause  of  death,  belong 
essentially  to  the  processes  of  decay  which  accompany  the  decline  of  life. 
But  though  heart  disease  is  confessedly  less  frequent  in  the  child  than 
in  the  youth  or  in  the  adult,  yet  its  rarity  is  not  so  great  as,  judging 
from  the  silence  concerning  it  of  most  writers  on  the  diseases  of  child- 
hood, you  might  naturally  infer.  On  turning  to  my  note-book,  I  find 
that  I  have  preserved  a  record  of  38  cases  of  disease  of  the  heart  in 
children  under  twelve  years  of  age,  and  cannot  doubt  but  that  more 
time  for  observing  my  patients,  or  more  sedulous  care  in  watching 
their  symptoms,  would  have  disclosed  to  me  its  existence  in  other 
instances. 

If,  then,  organic  disease  of  the  heart  be  not  very  common  in  the 
child,  at  least  it  is  not  so  unusual  as  to  warrant  our  passing  it  over 
without  notice ;  while  its  importance  is  increased  by  the  circumstance 
that  its  symptoms  are  in  many  instances  so  slight  at  first,  that  its  ex- 
istence may  be  overlooked,  until  the  evils  which  follow  in  its  train  force 
themselves  upon  our  attention. 

Acute  Rheumatism,  as  the  accompanying  Table1  shows^you,  is,  both 
before  as  well  as  after  puberty,  the  most  frequent  cause  of  inflammation 
of  the  external  investment  of  the  heart,  or  of  its  internal  lining.  The 
symptoms  of  rheumatism  are  essentially  the  same  at  both  periods  of  life, 
nor  is  there  any  peculiarity  required  in  their  treatment  in  the  case  of 
children,  beyond  that  diminution  in  the  doses  of  our  remedies  which  is 
called  for  by  the  tender  years  of  our  patients.  It  is  of  importance, 
however,  to  bear  in  mind,  that  the  risk  of  cardiac  mischief  supervening 
in  any  case  of  acute  rheumatism,  increases  in  direct  proportion  to  the 
youth  of  the  patient ;  and  that  the  mildness  of  the  general  symptoms, 
the  small  amount  of  pain  in  the  limbs,  and  the  almost  complete  absence 
of  swelling  of  the  joints,  afford  no  guarantee  that  the  heart  may  not 
become  the  seat  of  serious  disease.  It  happens,  too,  less  rarely  in  the 
case  of  children  than  of  the  adult,  that  the  general  indications  of  rheu- 
matism follow,  instead  of  preceding,  the  heart  affection ;  so  that  fever 
with  hurried  circulation  and  distinct  endocardial  murmur  may  exist  for 
two  or  three  days,  or  even  longer,  before  the  occurrence  of  pain,  and 
the  appearance  of  swelling  of  the  joints,  show  that  the  disease  of  the 
heart  is  only  a  part  of  the  great  malady  which  has  attacked  the  whole 
system. 

Every  threatening  of  rheumatism,  therefore,  is  to  be  watched  with  the 
most  anxious  solicitude  in  the  young  subject,  since  so  serious  a  compli- 
cation as  disease  of  the  heart  may  accompany  extremely  slight  general 
symptoms.  Nor  must  auscultation  be  neglected  in  cases  of  what  may 
seem  to  be  simple  fever,  since  rheumatic  inflammation  may  attack  the 
heart  before  any  other  signs  of  rheumatism  have  manifested  them- 
selves. 

1  The  Table  appended  to  this  lecture  shows  the  chief  points  of  interest  in  the  cases 
referred  to;  thirty  of  which  came  under  my  notice  at  the  Children's  Infirmary,  among  a 
total  of  13,798  children  under  twelve  years  of  age,  suffering  from  all  diseases. 


PERICARDITIS   COiMPLICATING  PLEURISY.  305 

Rheumatism,  however,  is  far  from  being  the  only  exciting  cause  of 
inflammation  of  the  pericardium,  or  of  the  lining  membrane  of  the  heart. 
It  may  supervene,  as  in  the  adult,  upon  some  disease,  such  as  scarlet 
fever,  in  the  course  of  which  the  composition  of  the  circulating  fluid 
becomes  altered,  of  which  three  instances  have  come  under  my  own  ob- 
servation ;  and  in  some  epidemics  of  scarlet  fever  it  would  seem  to  have 
been  far  from  an  unusual  complication  of  the  secondary  anasarca.1 

The  occurrence  of  acute  pericarditis  in  connection  with  acute  pleurisy 
is  an  accident  but  rarely  met  with ;  or  perhaps  it  would  be  more  correct 
to  say,  but  seldom  ascertained  to  exist,  except  in  cases  where  the  disease 
proves  fatal ;  for  on  examining  the  body  of  a  boy  eight  years  old,  whom 
I  had  treated  two  years  before  for  pleurisy  of  the  left  side,  I  was  sur- 
prised to  find  a  patch  of  old  lymph  on  the  left  ventricle,  near  the  apex 
of  the  heart,  and  a  good  deal  of  old  white  lymph  coating  the  right  au- 
ricle, and  white  spots  at  several  points  about  the  base  of  the  heart,  show- 
ing that  the  pericardium  had  been  the  seat  of  extensive  inflammation. 
The  affection  of  the  pericardium  in  most  of  these  cases  is  probably  se- 
condary to  that  of  the  pleura,  since  the  products  of  a  far  more  advanced 
inflammation  are  in  general  found  in  the  latter  cavity  than  the  former. 
In  some  instances  the  two  serous  membranes  would  seem  to  have  become 
affected  simultaneously,  while  in  others  the  indications  of  pericarditis 
are  perceptible  before  those  of  pleurisy  appear.  In  one  of  three  cases 
which  terminated  fatally,  the  patient,  a  little  girl  aged  sixteen  months, 
was  almost  moribund  when  she  came  under  my  notice :  convulsions  came 
on  in  two  or  three  hours,  and  she  died  after  they  had  continued  for 
twelve  hours.  In  this  instance  the  attack  had  commenced,  eight  days 
previously,  with  violent  sickness,  followed  by  severe  febrile  disturbance 
and  great  dyspnoea,  though  by  but  little  cough.  In  the  second  case, 
that  of  a  little  girl  aged  three  and  a  half  years,  slight  cough  and  febrile 
symptoms  had  existed  for  nearly  a  fortnight,  when  they  suddenly,  and 
without  any  obvious  cause,  became  greatly  aggravated ;  the  cough  grew 
constant,  short,  and  hacking ;  the  respiration  rose  to  72,  the  pulse  to 
156  in  the  minute.  The  child  became  extremely  restless,  appeared  to 
suffer  much,  made  frequent  efforts  to  vomit,  and  often  crammed  her 
hand  down  her  throat,  as  though  to  pull  something  away  which 
obstructed  her  breathing.  In  neither  of  these  cases  was  the  existence 
of  pericarditis  suspected.  In  the  last-mentioned  case  the  restlessness 
of  the  child  precluded  careful  auscultation ;  but  dulness  on  percussion, 
and  bronchial  breathing,  were  perceived  through  the  whole  of  the  poste- 
rior part  of  the  left  side  of  the  chest,  and  small  crepitation  was  heard 
on  the  right  side. 

In  the  third  case,  the  patient  was  a  little  girl  five  and  a  half  years  old, 
who  was  reported  to  have  had  frequent  attacks  of  inflammation  of  the 
chest,  but  who  was  in  good  health  at  the  time  of  her  being  seized  with 
vomiting,  followed  by  pain  in  the  head,  stomach,  and  back ;  and  cough, 
with  great  fever.  These  symptoms  had  continued  for  three  days  when 
she  came  under  my  notice.     Her  face  was  then  anxious,  her  skin  very 

1  As  in  the  epidemic  at  Dresden  in  1831,  as  described  by  Dr.  v.  Ammon  in  Analekten 
f.  Kinderkr,  Heft.  xi.  p.  42. 

20 


306  CASE   IN   ILLUSTRATION. 

hot ;  pulse  frequent,  quick,  and  wiry ;  respiration  hurried ;  and  she  had 
almost  constant  hard  cough,  which  occasioned  pain  in  the  epigastrium. 
She  complained  of  pain  in  the  left  side,  and  across  the  chest.  General 
subcrepitant  rale  was  heard  through  the  whole  chest.  There  was  exten- 
sive dulness  in  the  precordial  region :  a  loud,  rough,  bellows  murmur 
accompanied  the  first  sound  of  the  heart  at  the  apex,  and  a  similar 
sound  was  distinguished  at  the  base,  where  it  was  suspected  to  be  the 
commencement  of  a  to-and-fro  sound.  The  child  was  bled  from  the  arm, 
leeches  were  applied  over  the  heart,  and  two  grains  of  calomel,  with  one- 
sixth  of  a  grain  of  tartar  emetic,  were  given  every  three  hours  ;  but  on 
the  following  day  her  general  condition  was  unchanged — the  bruit  with 
the  first  sound  of  the  heart  continued  at  the  apex ;  and  that  at  the  base 
was  now  a.  distinct  to-and-fro  sound ; — in  addition  to  which  a  loud, 
pleural  friction  sound  was  heard  over  both  sides  of  the  chest  posteriorly. 
The  remedies  were  continued,  but  by  the  next  day  the  child's  condition 
had  deteriorated.  The  results  of  auscultation  were  much  the  same  as 
before,  but  the  pleural  friction  sound  had  almost  completely  disappeared, 
and  percussion  yielded  a  dull  sound  in  both  infra-scapular  regions. 
Circumstances  prevented  my  watching  the  child  during  the  ensuing 
forty-eight  hours,  at  the  end  of  which  time  she  died — eight  days  after 
the  commencement  of  her  illness.  A  post-mortem  examination  was  not 
made;  but  there  can  be  no  doubt  but  that  it  would  have  disclosed 
appearances  similar  to  those  observed  in  the  other  two  cases,  except  that 
probably  evidences  of  inflammation  of  the  endocardium  would  have  been 
associated  with  those  of  pericarditis,  and  that  the  affection  of  the  pleura 
would  have  been  found  to  be  secondary  to,  and  less  extensive  than,  that 
of  the  heart. 

There  is  little  danger,  in  cases  which  set  in  with  symptoms  so  severe 
as  those  just  described,  of  our  falling  into  serious  error,  either  of  diag- 
nosis or  treatment.  Every  thing  would  point  to  most  serious  mischief 
in  the  chest ;  and  even  should  the  tender  age  of  the  child,  and  its 
extreme  restlessness,  prevent  careful  auscultation,  or  should  the  signs 
of  heart  disease  be  masked  by  those  of  mischief  in  the  lung  or  pleura, 
enough  will  yet  be  discovered  to  show  the  necessity  for  immediate  and 
active  interference ;  while,  if  we  bear  in  mind  the  possibility  of  such  a 
complication,  that  will  go  far  towards  preventing  us  from  overlooking 
its  occurrence. 

Inflammation  of  the  pericardium,  or  of  the  lining  membrane  of  the 
heart,  or  both,  sometimes  comes  on  unaccompanied  with  any  affection 
of  the  lungs  or  pleura ;  and  in  such  cases  the  indications  of  disturbance 
of  the  respiration  are  either  altogether  absent,  or  comparatively  slight. 
If  auscultation  be  neglected,  or  but  carelessly  performed,  disease  may, 
under  such  circumstances,  go  on  unchecked  till  it  has  disorganized  the 
heart,  and  doomed  the  patient  to  a  life  of  remediless  suffering. 

A  striking  instance  of  this  idiopathic  inflammation  of  the  pericar- 
dium and  lining  membrane  of  the  heart  came  under  my  notice  some 
time  since,  in  the  person  of  a  healthy  boy,  eleven  years  old,  who,  on 
May  8,  1843,  complained  of  feeling  cold,  and  began  to  cough.  The 
chilliness  was  succeeded  by  fever,  and  he  continued  gradually  getting 
worse  till  the  13th,  when  I  visited  him  for  the  first  time.     He  had  had 


IDIOPATHIC   PERICARDITIS.  307 

no  other  medicine  than  a  purgative  powder.  On  May  13th  I  found 
him  lying  in  bed;  his  face  dusky  and  rather  anxious;  his  eyes  heavy, 
and  his  respiration  slightly  accelerated;  coughing  frequently,  but  with- 
out expectoration ;  skin  burning  hot ;  pulse  frequent  and  hard.  He 
made  no  complaint,  except  of  slight  uneasiness  about  the  left  breast. 
On  examining  the  chest  there  was  found  to  be  very  extended  dulness 
over  the  heart,  with  slight  tenderness  on  pressure.  A  very  loud  and 
prolonged  rasping  sound  was  heard  in  the  place  of  the  first  sound, 
loudest  a  little  below  the  nipple,  though  very  audible  ever  the  whole 
left  side  of  the  chest,  and  also  distinguishable,  though  less  clearly,  for 
a  considerable  distance  to  the  right  of  the  sternum.  The  second  sound 
was  heard  clearly  just  over  the  aortic  valves,  but  was  not  distinct  else- 
where, being  obscured  by  the  loudness  of  the  bruit.  Respiration  was 
good  in  both  lungs. 

The  child  was  cupped  to  six  ounces  between  the  left  scapula  and 
the  spine ;  and  a  grain  of  calomel,  with  the  same  quantity  of  Dover's 
powder,  was  given  every  four  hours. 

On  the  following  day  it  was  found  that  the  sense  of  discomfort  in  the 
chest  had  been  relieved  by  the  cupping,  and  that  the  child  had  slept 
well  in  the  night.  He  looked  less  anxious,  though  his  eyes  were  still 
heavy  and  suffused,  and  his  skin  was  less  hot  and  less  dusky.  His 
pulse  was  114,  thrilling,  but  not  full.  There  was  now  slight  prominence 
of  the  cardiac  region,  and  the  heart's  sounds  were  obscurer  and  more 
distant  than  on  the  previous  day.  The  bruit  was  now  manifestly  a 
friction  sound,  louder  at  the  base  than  at  the  apex  of  the  heart,  and 
altogether  obscuring  the  first  sound;  while  the  second  sound  could  be 
heard  over  the  aortic  valves.  Six  more  leeches  were  applied  over  the 
heart,  and  the  haemorrhage  from  their  bites  was  so  profuse  as  to  occa- 
sion some  faintness.  Mercurial  inunction  was  now  superadded  to  the 
treatment  previously  employed;  and  the  child's  condition  continued 
through  the  15th  to  be  much  the  same  as  it  had  been  on  the  previous 
day.  On  May  16th  there  was  some  improvement  in  the  general  symp- 
toms, and  the  pulse  was  softer.  The  friction  sound  was  now  no  longer 
audible,  but  a  loud  rasping  sound  was  heard  in  place  of  the  first 
sound.  The  second  sound  was  now  distinguishable  at  the  apex  of  the 
heart,  as  well  as  over  the  aortic  valves,  and  its  characters  were  quite 
natural.  On  the  19th  the  child's  mouth  was  slightly  sore,  and  the  dose 
of  the  remedies  was  diminished.  On  the  22d  the  soreness  of  the 
mouth  was  considerable,  and  all  active  treatment  was  discontinued  on 
that  day.  The  child  gradually  regained  his  strength,  but  the  bruit 
accompanying  the  first  sound  continued  and  was  heard  a  month  after- 
wards, with  no  other  change  than  being  rather  softer  and  more 
prolonged.  Four  years  afterwards  I  saw  him  again.  He  had  con- 
tinued well  in  the  interval,  and  had  never  suffered  from  palpitation  of 
the  heart,  nor  from  any  other  ailment  referrible  to  the  chest ;  but  his 
pulse  was  small,  jerking,  and  not  always  equal  in  force;  and  the  natural 
character  of  the  first  sound  was  altogether  lost  in  a  loud  prolonged 
bruit. 

In  cases  such  as  this  the  occurrence  of  the  heart  disease  is  not  easy 
of  explanation.     No  sign  of  rheumatism  appeared  during  the  whole 


308  IDIOPATHIC   PERICARDITIS. 

course  of  the  affection,  nor  was  it  associated  with  any  other  disorder, 
such  as  scarlatina,  which,  by  the  alterations  that  it  induces  in  the  com- 
position of  the  circulating  fluid,  could  be  supposed  to  favour  the  super- 
vention of  inflammation  of  the  heart  or  other  viscera.1  The  organs  of 
respiration  were  unaffected  throughout,  so  that  the  case  could  not  for  a 
moment  be  conceived  to  be  one  in  which  the  heart  disease  was  secondary, 
and  produced  by  the  extension  of  the  inflammation  beyond  the  limits 
by  which  it  was  originally  circumscribed.  But  though  the  cardiac 
affection  came  on  independently  of  those  conditions,  which  we  regard, 
and  with  justice,  as  usually  essential  to  its  production,  it  ran  as  acute  a 
course,  and  produced  injury  as  extensive,  as  if  it  had  been  excited  by 
any  of  its  ordinary  causes ;  and  left,  it  is  to  be  feared,  as  abiding  a 
disorganization  of  the  heart. 

Idiopathic  pericarditis,  uncomplicated  with  pleurisy,  and  sufficiently 
severe  to  give  rise  to  symptoms  appreciable  during  the  life-time  of  the 
patient,  is  a  very  rare  occurrence,  and  I  have  seen  but  one  other  instance 
of  it.  Unfortunately,  I  cannot  speak  with  accuracy  as  to  the  frequency 
in  early  life  of  those  slight  inflammations  of  the  pericardium  which  give 
rise  to  the  white  spots  upon  its  surface,  shown  by  M.  Bizot  and  Mr. 
Paget2  to  be  so  common  in  the  adult ;  for  I  have  not  always  recorded 
their  presence  or  absence  in  my  notes  of  dissection.  My  impression, 
indeed,  is,  that  they  are  much  rarer  in  early  life  than  in  the  grown 
person ;  but  I  found  extremely  extensive  old  deposits  of  lymph  on  the 
heart  of  a  boy,  who  died  at  the  age  of  eight  months,  of  congestion  of 
the  brain,  and  who  was  not  known  to  have  suffered  from  any  chest 
affection,  beyond  the  catarrhal  ailments  of  infancy ;  while  their  presence 
in  an  infant  aged  only  four  months,  whose  case  is  related  at  page  314, 
shows  that  there  is  no  age  so  early  as  to  be  exempt  from  pericardial 
inflammation. 

Idiopathic  endocarditis  is  less  uncommon,  and  appears  to  be  governed 
by  the  same  laws,  and  to  give  rise  to  the  same  symptoms,  as  when  it 
complicates  acute  rheumatism.  Uneasiness,  or  actual  pain  at  the  heart, 
increase  of  its  impulse,  acceleration,  perhaps  irregularity,  of  its  action, 
dyspnoea,  a  livid  countenance,  and  threatening  suffocation,  are  the  signs 
by  which  it  betrays  itself  to  the  observer.  But,  just  as  in  rheumatic 
endocarditis,  these  symptoms  may  vary  in  degree,  and  be  in  one  case  so 
severe  as  to  force  themselves  upon  our  notice,  and  in  another  so  slight 
as  almost  to  elude  our  observation,  so  it  is  in  cases  where  the  endocar- 
ditis is  idiopathic.  In  cases  of  acute  rheumatism  you  are  aware  of  this 
danger ;  you  do  not  wait  till  the  patient's  sufferings  inform  you  that  the 
mischief  has  been  done,  but  you  are  on  the  watch  against  the  first  threat- 
enings  of  its  approach, — and  your  sense  of  hearing  gives  you  earlier 
information,  and  surer  information,  concerning  this  than  all  the  other 
signs  together.  But  if  the  same  evil,  against  which  you  guard  thus 
sedulously  in  cases  of  rheumatism,  may  occur  independently  of  it,  and 

1  As  Bright's  disease,  for  instance,  in  the  adult  favonrs  the  occurrence  of  pericarditis, 
according  to,  the  elaborate  researches  of  Dr.  Taylor,  in  vol.  xxviii.  of  the  Medico-Chi- 
rurgical  Transactions. 

2  Me'moires  de  la  Socict6  M6d.  d'Observation,  tome  I  p.  350  ;  and  Medico-Chirurgical 
Transactions,  vol.  xxiii. 


IDIOPATHIC   ENDOCARDITIS.  309 

may  scarcely  give  warning  of  its  approach,  until  it  is  almost  or  altogether 
too  late  to  cure,  a  measure  at  least  of  the  same  precaution  should  be 
observed  at  all  times ;  and  in  no  instance  of  febrile  disturbance  in  early 
life,  how  simple  soever  the  case  may  seem,  should  you  consider  the 
examination  of  the  patient  complete  until  after  auscultation.  With  all 
your  care,  there  will  probably  still  be  cases  in  which  the  commencement 
of  the  heart  affection  will  escape  your  notice ;  in  which  you  will  acciden- 
tally make  the  discovery  of  its  existence  when  auscultating  the  chest  for 
some  other  purpose,  or  in  which  the  gradual  supervention  of  the  signs 
of  valvular  disease  will  call  your  attention  to  it  long  after  the  ailment 
has  become  chronic. 

The  early  detection  of  the  disease  is  of  the  more  importance,  since  its 
gradual  approach  affords  no  assurance  that  it  may  not  go  on  to  ruin  the 
health,  and  at  length  destroy  the  life  of  the  sufferer.  Nothing  could  be 
more  gradual  than  the  advance  of  the  early  stages  of  the  disease  of  the 
heart,  in  the  case  of  a  little  girl,  ten  years  old,  who  came  under  my 
notice  in  the  month  of  March,  some  years  ago.  Her  mother  stated, 
that,  though  not  robust,  she  had  never  had  any  definite  illness,  but  that 
for  the  last  year  she  had  been  growing  thinner,  and  had  suffered  from 
palpitation  of  the  heart,  which  had  by  degrees  become  more  and  more 
distressing,  and  that  for  the  past  three  months  she  had  likewise  suffered 
from  cough.  The  child  when  brought  to  me  was  greatly  emaciated ;  her 
face  was  anxious  and  distressed;  her  breath  short,  so  that  it  was  with 
difficulty  that  she  walked  even  a  short  distance ;  she  had  frequent  short 
cough,  without  expectoration,  and  she  suffered  much  from  palpitation  of 
the  heart,  and  a  sense  of  discomfort  at  the  chest.  The  heart's  action 
was  violent ;  fulness  in  the  precordial  region  was  extended  ;  a  very  loud, 
harsh,  rasping  sound  accompanied  the  first  sound  of  the  heart,  loudest 
towards  and  to  the  left  of  the  nipple,  but  heard  over  the  whole  of  the 
chest,  both  before  and  behind.  Various  remedies  brought  slight  but 
temporary  relief  to  her  sufferings,  and  she  grew  worse  every  month. 
She  became  more  and  more  emaciated;  the  distress  at  the  chest,  and 
the  palpitation  of  the  heart,  increased,  her  cough  became  more  violent, 
and  once  she  had  an  attack  of  haemoptysis.  For  about  a  month  before 
her  death  the  cough  altogether  ceased,  but  she  was  now  unable  to  leave 
her  bed,  from  increasing  weakness ;  the  palpitation  continued  unmiti- 
gated, and  her  extremities  became  slightly  anasarcous.  During  the 
last  week  of  her  life  her  respiration  was  extremely  difficult,  and  became 
increasingly  so,  till  she  died  on  the  10th  of  October.  The  lungs  were 
very  emphysematous,  and  much  congested,  but  not  otherwise  diseased. 
The  heart  was  extremely  large,  but  its  right  cavities  did  not  exceed  the 
natural  size ;  the  pulmonary  valves  were  healthy ;  the  edges  of  the 
tricuspid  valve  were  slightly  thickened ;  the  left  auricle  was  enormously 
dilated,  but  its  walls  were  not  at  all  attenuated ;  the  pulmonary  veins 
were  much  dilated ;  the  left  ventricle  was  dilated,  its  walls  were  thick- 
ened; the  chordae  tendineae  of  the  mitral  valve  were  greatly  shortened, 
so  that  the  valve  could  not  close ;  the  valve  itself  was  shrunken,  thick- 
ened, and  cartilaginous ;  and  there  existed  likewise  slight  thickening  of 
the  edges  of  the  semilunar  valves  of  the  aorta. 

The  symptoms  in  this  case,  from  the  earliest  period  to  which  the 


310  TENDENCY   OF   VALVULAR   DISEASE   TO   INCREASE. 

patient's  history  goes  back,  were  those  of  chronic  valvular  disease  with 
hypertrophy  and  dilatation  of  the  heart ;  but  no  clue  is  afforded  us  by 
which  we  can  guess  when  the  inflammation  of  the  endocardium,  the  first 
in  this  train  of  evils,  attacked  the  heart.  The  constitutional  distur- 
bance which  attended  it  was  so  slight  as  to  escape  the  mother's  notice, 
and  to  call  for  no  special  complaint  from  the  child  :  but  it  is  probable 
that  more  watchful  care  would  have  taken  the  alarm  at  some  compara- 
tively slight  feverish  seizure  ;  that  auscultation  would  have  discovered 
the  disease  at  its  commencement ;  and  that  treatment  would  have 
diminished,  though  it  might  not  have  altogether  prevented,  the  subse- 
quent disorganization  of  the  heart. 

The  general  tendency  of  the  disease  in  the  child,  as  in  the  adult, 
seems  to  be,  to  go  on  from  bad  to  worse  ;  and  the  endocardium,  once 
inflamed,  appears  to  have  acquired  an  increased  liability  to  become  the 
seat  of  renewed  inflammatory  action.  Thus,  a  little  boy,  who  came 
under  my  notice  a  few  years  ago,  with  all  the  symptoms  of  acute  endo- 
carditis, with  dyspnoea,  inability  to  assume  the  recumbent  posture, 
palpitation  of  the  heart,  and  irregularity  of  its  pulsations,  extended 
dulness  in  the  precordial  region,  and  a  loud  bruit  accompanying  the 
first  sound,  was  reported  to  have  had  a  similar  attack  two  years  before, 
from  which  it  was  many  weeks  before  he  perfectly  recovered.  A  little 
girl  was  attacked,  when  three  and  a  quarter  years  old,  with  slight 
febrile  symptoms,  soon  followed  by  uneasiness  at  the  chest,  shortness 
of  breath,  and  palpitation ;  while  a  loud  bruit,  heard  both  at  the  base 
and  apex  of  the  heart,  showed  that  its  lining  membrane  had  become 
the  seat  of  disease.  The  general  symptoms  were  relieved,  but  the  child 
remained  short-breathed  and  liable  to  palpitation,  and  the  physical 
signs  of  injury  to  the  valves  continued  unchanged  when  she  was  five 
years  old.  At  the  age  of  seven  I  saw  her  again,  and  learned  that  she 
had  during  the  previous  two  years  complained  frequently  of  shortness 
of  breath,  and  pain  in  her  chest ;  that  she  had  become  unable  to  walk 
more  than  a  short  distance ;  while  under  any  unusual  exertion  her  lips 
and  face  became  quite  livid.  She  was  brought  to  me,  however,  at  this 
time,  in  consequence  of  a  sudden  aggravation  of  these  symptoms  having 
followed  exposure  to  cold  ;  which,  moreover,  had  occasioned  a  very 
violent  cough,  and  severe  pain  in  the  left  side.  The  dulness  in  the 
precordial  region  now  extended  over  a  somewhat  larger  space  than 
natural,  and  the  first  sound  of  the  heart  was  completely  masked  at  the 
apex  by  a  loud,  harsh$  murmur,  which  was  heard  in  a  still  harsher  key 
over  the  aortic  valves,  and  was  likewise  continued  for  some  distance 
along  the  aorta. 

The  increase  of  the  child's  sufferings  was  but  temporary,  and  when 
she  had  regained  her  usual  health,  I  again  lost  sight  of  her  for  some 
years.  In  May,  1848,  however,  I  had  the  opportunity  of  seeing  her, 
and  of  again  examining  her  chest.  She  was  then  ten  years  and  a  half 
old ;  tall  for  her  age,  and  tolerably  well  nourished,  but  there  was  a 
livid  flush  constantly  on  her  face ;  her  extremities  were  cold  ;  her  pulse 
108,  small,  and  unequal  in  power.  Her  mother  stated  that  she  was 
unable  to  walk  a  couple  of  hundred  yards  without  suffering  from  violent 
palpitation,  and  from  pain  about  and  across  the  epigastrium,  and  that 


CASES   OF  VALVULAR   DISEASE —  311 

during  these  attacks  she  turned  quite  blue,— symptoms  all. of  which 
had  become  much  more  marked  during  the  preceding  twelve  months. 
The  dulness  in  the  precordial  region  was  now  very  extended;  the 
results  of  auscultation  continued  the  same,  but  the  hand  distinguished 
a  slight  fremissement  when  placed  over  the  heart. 

It  is  easy,  in  this  case,  to  infer  from  the  past  what  will  be  the  future 
history  of  this  poor  child.  The  valvular  disease,  and  the  heart's  efforts 
to  overcome  its  consequences,  have  already  led  to  a  considerable  degree 
of  hypertrophy  of  the  organ ;  the  danger  of  each  acute  attack  will  be 
aggravated  by  the  old  disease,  and  every  fresh  inflammatory  seizure  will 
add  to  the  chronic  mischief,  until  in  course  of  time  the  disorganization 
of  the  heart  will  have  advanced  so  far  as  to  render  it  unable  to  perform 
its  office  sufficiently  well  to  maintain  existence  any  longer,  and  a  life 
of  suffering  will  then  be  closed  by  a  painful  death. 

Such  was  her  condition,  and  such  seemed  to  be  her  prospects,  three 
years  ago.  I  have  seen  her  again  in  June  of  the  present  year,  and 
slowly,  but  surely,  these  sad  prophecies  are  in  course  of  fulfilment. 
The  livid  flush,  the  feeble  pulse,  and  the  dyspnoea,  continue  ;  even  the 
sitting  posture  is  now  a  source  of  discomfort  to  her,  and  she  cannot 
bear  it  long,  for  her  heart  is  so  damaged  that  it  can  do  its  work  reason- 
ably well  only  when  reclining,  and  in  a  state  of  absolute  repose. 

But,  you  may  ask,  is  a  prognosis  so  gloomy  to  be  formed  with  refer- 
ence to  every  case  in  which  our  ear  informs  us  there  is  something  wrong 
about  the  heart  ?  Dr.  Latham, — whose  name  I  cannot  mention  without 
the  expression  of  respect  and  gratitude  due  to  one  to  whose  instructions 
I  owe  so  much, — mentions  the  case  of  two  young  ladies,  in  whom  the 
auscultatory,  signs  of  valvular  imperfection  have  existed  from  early 
childhood,  but  who  have  never  suffered  any  important  disturbance  of 
the  general  health  that  could  be  attributed  to  it.  With  reference  to 
these  and  other  similar  cases,  he  says,  "Do  not  these  facts  give  intima- 
tion of  a  certain  protective  power,  possibly  inherent  in  the  growing 
heart,  whereby  it  can  accommodate  its  form  and  manner  of  increase 
to  material  accidents,  and  so  repress  or  counteract  their  evil  tenden- 
cies  :  a 

Cases  that  seem  to  show  the  existence  of  such  a  power  have  come 
under  my  own  notice,  and  some  time  since  I  watched  a  striking  illus- 
tration of  it  with  much  interest.  A  little  girl,  six  years  old,  whose 
health  had  never  been  robust,  and  who  had  suffered  much  from  measles 
and  scarlatina,  the  latter  of  which  left  her  liable  to  attacks  of  what 
was  said  to  be  inflammation  of  the  chest,  came  under  my  notice  at  the 
end  of  April,  1846.  She  was  then  labouring  under  urgent  dyspnoea, 
with  symptoms  of  acute  bronchitis,  and,  in  the  course  of  auscultation,  a 
systolic  murmur  was  heard  at  the  apex  of  the  heart.  The  bronchitic 
symptoms  by  degrees  subsided,  but  dyspnoea  continued ;  the  child  was 
wholly  unable  to  rest,  except  when  propped  nearly  upright ;  she  was 
distressed  by  palpitation  ;  her  cough  was  frequent,  and  when  worse 
than  usual,  she  expectorated  with  it  small  quantities  of  florid  blood. 
Her  face  was  pale,  but  with  a  livid  flush  on  either  cheek  ;  the  carotids 

1  On  Diseases  of  the  Heart,  vol.  i.  p.  241-3. 


312  TENDENCY   OF   THE   DISEASE   TO   INCREASE. 

pulsated  visibly,  and  the  jugular  veins  were  distended,  while  her  heart 
beat  at  the  rate  of  150  in  a  minute.  The  heart's  impulse  was  increased, 
and  dulness  in  the  precordial  region  extended  far  beyond  its  proper 
limits/  It  was  next  noted  that  the  smallness  of  the  pulse  corresponded 
ill  with  the  labouring  of  the  heart;  and  a  distinct  sense  of  J remiss  em  ent, 
when  the  hand  was  laid  upon  the  precordial  region,  completed  the 
signs  of  great  contraction  of  the  mitral  orifice,  with  hypertrophy  and 
dilatation  of  the  heart.  From  time  to  time  the  child  suffered  much  since 
then  with  a  return  of  her  old  symptoms ;  and,  after  the  lapse  of  twenty 
months,  the  bruit  still  continued:  the  hand  placed  upon  the  cardiac 
region  Was  still  sensible  of  a  distinct  purring  tremor,  and  the  pulse  was 
exceedingly  small  and  feeble.  But  the  heart  no  longer  laboured  as  it 
used  to  do  ;  its  pulsations  did  not  exceed  110  in  the  minute ;  and  though 
the  child  was  still  unable  to  lie  flat  in  the  bed,  the  distressing  orthopncea 
had  ceased  for  many  months.  Her  eyelids  were  no  longer  puffy,  nor 
her  limbs  anasarcous,  as  they  were  before ;  her  cough  troubled  her  but 
little,  and  haemoptysis  was  very  rare.  She  had  gained  flesh,  was 
cheerful,  and  played,  though  not  so  boisterously  as  other  children  might 
do,  yet  with  such  heartiness,  that  I  could  scarcely  believe  her  to  be  the 
little  suffering  thing  for  whom,  a  year  before,  one  would  have  chosen 
speedy  death  as  the  happiest  lot  that  could  befal  her. 

But  though  this  case  made  a  great  impression  on  me,  as  seeming  to 
shew  how  large  a  power  the  growing  organ  possesses  to  adapt  itself 
to  a  diseased  condition,  yet  I  should  fear  that  the  state  of  almost  com- 
plete immunity  from  evil  consequences  which  was  the  good  fortune  of 
the  young  ladies  mentioned  by  Dr.  Latham,  must  be  confined  to  cases 
in  which  nothing  existed  more  serious  than  some  slight  congenital 
imperfection ;  and  that  we  cannot  hope  for  so  happy  a  result  in  any 
instance  in  which  the  heart  has  been  damaged  by  inflammation.  The 
subject  is  one  on  which  I  would  speak  with  great  diffidence ;  but  it  has 
seemed  to  me  that,  how  slight  soever  the  mischief  may  have  been  which 
a  first  attack  of  endocarditis  inflicted,  a  second  attack  is  almost  sure  to 
be  excited  by  some  most  trivial  cause,  and  then  a  third,  until  the  injury 
becomes  irremediable,  and  its  consequences  such  as  nature,  though  she 
may  alleviate,  is  yet  unable  to  remove.  If  the  evil  be  congenital,  the 
heart  may  perhaps  accommodate  itself  so  completely  to  it  as  to  do 
away  with  all  that  made  it  serious  ;  but  if  the  damage  be  produced  by 
disease,  the  chances  of  that  disease  returning  and  aggravating  it  are 
so  great  as  to  forbid  our  entertaining  sanguine  hopes  with  reference  to 
what  nature  may  be  able  to  effect ;  and  even  in  the  case  of  the  little 
girl  whose  history  I  have  just  related  the  improvement  has  probably 
reached  its  limit ;  for  though  she  remained  tolerably  free  from  suffer- 
ing, yet  at  the  age  of  9  years  all  the  physical  signs  of  her  disease  were 
increased  rather  than  diminished  :  she  was  still  unable  to  lie  down  in 
bed  ;  and  the  least  cold  brought  back  all  her  former  symptoms. 

There  is  one  more  point  to  which,  before  quitting  this  subject,  I  must 
advert,  since  it  tends  to  give  a  graver  character  in  every  instance  to  the 
auscultatory  signs  of  cardiac  disease  in  early  life,  than  belongs  to  them 
invariably  in  the  adult.  It  is  unnecessary  to  describe  to  you  the  peculiar 
murmur  heard  in  the  heart  and  large  vessels  in  the  adult,  in  many  cases 


RARITY   OF   ANAEMIC   BRUITS   IN   THE   CHILD.  313 

in  which  no  heart  disease  exists ;  but  which  is  associated  with  a  general 
condition  of  angemia,  and  ceases  to  be  audible  when  tonic  remedies  or 
abundant  nutriment  have  reinvigorated  the  patient's  frame.  I  have 
often  sought  for,  but  have  never  heard,  those  endocardial,  arterial,  or 
venous  murmurs  which  are  produced  by  an  impoverished  state  of  the 
blood  in  children  under  seven  years  old ;  and  even  at  a  later  period 
they  are  exceedingly  rare,  until  that  age  is  attained  at  which  the 
changes  that  take  place  as  puberty  approaches  have  already  commenced, 
or  are  on  the  eve  of  beginning,  though  in  three1  of  the  cases  enumerated 
in  the  table,  in  which  an  endocardial  murmur  was  heard  in  conjunction 
with  acute  febrile  symptoms,  it  afterwards  became  so  faint  as  to  warrant 
the  hope  that  it  was  due  merely  to  functional  disorder,  and  would  even- 
tually disappear.  Of  the  rarity  of  such  murmurs  I  think  that  I  may 
speak  with  certainty,  but  I  will  not  venture  to  assign  a  reason  for  it, 
since  the  very  slight  difference  between  the  composition  of  the  blood  in 
early  childhood  and  in  after  life  can  scarcely  be  regarded  as  affording 
a  sufficient  explanation  of  it. 

It  might  perhaps  seem  to  you  that  I  had  been  guilty  of  a  serious 
omission,  if  I  were  to  conclude  this  lecture  on  the  affections  of  the  heart, 
without  some  mention  of  those  symptoms  which  are  observed  in  cases 
wThere  the  heart  has  been  malformed  from  birth.  From  one  of  the 
most  striking  of  these  symptoms — a  peculiar  lividity  of  the  surface, 
produced  by  the  circulation  through  the  body  of  imperfectly  aerated 
blood — the  term  cyanosis  has  been  applied  to  this  morbid  condition. 
It  was  once  supposed  that  the  admixture  of  venous  with  arterial  blood, 
owing  to  the  imperfect  closure  of  some  of  the  foetal  passages  of  com- 
munication between  the  two  sides  of  the  heart,  was  sufficient  to  produce 
this  livid  colour  of  the  surface,  and  must  invariably  give  rise  to  it. 
This,  however,  is  by  no  means  the  case,  and  we  are  now  aware  that 
something  more  than  the  mere  patescence  of  the  foetal  openings  is  in 
general  necessary  to  produce  the  cyanosis,  the  cold  surface,  the 
occasional  attacks  of  suffocation,  and  those  other  symptoms  which  used 
to  be  regarded  as  characteristic  of  this  defect  of  development.  Cases 
are  on  record  in  which  such  defects  have  not  manifested  themselves  by 
any  symptoms  until  the  patient  had  grown  up  to  childhood,  or  had  even 
attained  to  adult  age ;  while  even  then  their  consequences  have  some- 
times been  slight  and  of  short  duration,  and  have  shewn  themselves  but 
seldom ;  or,  on  the  other  hand,  having  manifested  themselves  a  few 
weeks  before  death,  they  have  recurred  with  ever  increasing  intensity, 
until  they  destroyed  life.  Nor  are  these  the  only  circumstances  which 
render  the  study  of  congenital  malformations  of  the  heart  difficult  and 
intricate ;  but  diseases  acquired  in  after  life  sometimes  give  rise  to 
similar  symptoms;  and  aneurism  in  the  grown  person,  or  valvular 
disease  in  the  young,  occasionally  assumes  many  of  the  characters  that 
commonly  belong  to  defects  in  the  original  structure  of  the  heart.  To 
do  justice  to  the  subject,  therefore,  would  require  that  we  should  enter 
upon  a  field  of  pathological  inquiry,  interesting  indeed,  but  in  which 
we  should  be  drawn  aside  from  that  special  investigation  of  the  diseases 
of  childhood  which  is  our  business  now. 

1  Nos.  2,  10,  and  25  in  the  Table. 


314  MALFORMATIONS  OF  THE  HEART. 

I  shall,  therefore,  merely  lay  before  you  my  personal  experience  of 
cases  of  cyanosis,  which  is  but  small,  since  it  includes  only  two  cases  in 
which  the  nature  of  the  affection  was  demonstrated  by  examination  after 
death ;  and  a  third,  in  which,  though  the  patient  still  lives,  yet  her 
symptoms  are  so  well  marked  as  to  preclude  much  doubt  as  to  their 
cause. 

The  first  of  these  cases  is  interesting,  not  merely  as  an  instance  of 
congenital  malformation  of  the  heart,  but  as  affording  a  striking  illus- 
tration of  the  influence  which  malformation  exerts  in  predisposing  to 
other  diseases  of  the  organ.  The  patient,  a  little  boy,  who  was  four 
months  old  when  he  died,  did  not  come  under  my  notice  until  the  day 
of  his  death.  The  history  which  I  heard  of  him  was,  that  he  was  very 
livid  at  birth,  that  respiration  was  established  with  difficulty,  and  that 
the  dark  hue  of  his  surface  never  went  off  completely.  At  times  he 
seemed  cheerful,  and  used  to  breathe  pretty  well,  but  at  other  times  he 
was  seized,  without  apparent  cause,  with  difficult  respiration,  during 
which  he  became  very  cold  and  quite  purple,  made  a  grunting  noise, 
and  frothed  at  the  mouth.  These  attacks  never  came  on  while  he  was 
sucking ;  they  were  preceded  by  crying,  though  usually  he  was  very 
quiet. 

On  October  19,  1848.,  an  attack  came  on,  similar  to  the  previous 
seizures,  though  more  severe,  lasting  between  one  and  two  hours,  and 
not  being  preceded  by  crying.  On  the  20th,  a  similar  attack  came  on, 
and  lasted  from  4  to  7}  P.  M.,  and  another  returned  on  the  morning  of 
the  24th,  at  noon  of  which  day  he  was  brought  to  me.  His  surface 
was  then  generally  very  pale,  but  with  a  marked  livid  hue  of  the  lips 
and  fingers,  and  around  the  mouth.  His  skin  was  cool,  almost  cold ; 
his  respiration,  irregular  and  very  frequent,  and  his  pulse  extremely 
feeble.  Auscultation  detected  no  unnatural  sound  with  the  heart's 
action. 

As  he  was  being  carried  home  a  fresh  seizure  came  on,  and  proved 
fatal  in  half  an  hour. 

The  lungs  and  pleurae  generally  were  healthy. 

The  pleura,  where  it  is  in  contact  with  the  pericardium,  and  that 
membrane  itself,  were  of  a  bright  red  colour,  with  the  vessels  minutely 
injected.  This  sac  of  the  pericardium  contained  5J.  of  a  dirty, 
yellowish,  sero-purulent  fluid,  in  which  little  granules  of  lymph,  like 
minute  grains  of  rice,  were  floating.  It  did  not  any  where  adhere  to 
the  heart,  but  its  parietal  layer,  which  was  intensely  red,  and  beset 
with  numerous  little  ecchymoses,  was  lined  through  a  great  extent  by 
a  thin  layer  of  lymph.  This  layer  was  thicker  on  the  right  than  on 
the  left  half  of  the  pericardium,  and  especially  so  about  the  right 
auricle.  Lymph  was  also  deposited  between  the  left  auricle  and  the 
root  of  the  pulmonary  artery. 

The  pericardium  investing  the  heart  was  intensely  red,  and  numerous 
small  flocculi  of  lymph  covered  its  surface.  Besides  this,  there  was  an 
old  white  spot,  half  an  inch  long  by  a  quarter  of  an  inch  broad,  at  the 
apex  of  the  left  ventricle,  having  just  the  character  of  the  white  spots 
of  old  pericarditis;  and  there  was  another  small  spot  on  the  posterior 
surface  of  the  right  auricle. 


ILLUSTRATIVE   CASES.  315 

The  foramen  ovale  was  wide  open,  so  as  to  admit  the  finger  with  ease  ; 
the  pulmonary  artery  was  very  small :  the  ductus  arteriosus  wide  open, 
and  the  septum  of  the  ventricles  very  imperfect :  the  ductus  venosus 
was  closed. 

In  the  second  case  the  patient  was  a  little  girl,  whom  I  saw  when  she 
was  three  months  old.  She  was  stated  to  have  been  healthy  when  born, 
and  to  have  continued  so  till  two  months  old,  when  an  eruption,  appa- 
rently of  a  syphilitic  character,  broke  out  upon  her  body,  and  her 
health  since  then  had  failed.  The  condition  in  which  she  was  when 
brought  to  me  had  been  coming  on  gradually  for  three  weeks.  She 
was  small,  but  not  emaciated ;  her  skin  was  pale  as  marble,  and  rather 
cold;  her  buttocks  were  covered  with  the  scars  of  a  syphilitic  eruption, 
which  had  nearly  faded.  A  large  purpurous  spot  on  the  abdomen,  near 
the  umbilicus,  surrounded  the  ill-formed  scab  of  a  vesicle  which  had 
been  situated  there.  A  large  ecchymosis  had  formed  in  the  left  hypo- 
chondriac region,  and  another  similar  one  on  the  left  wrist,  and  the 
legs  were  covered  with  petechia.  The  child  seemed  feeble,  and  its  cry 
was  very  faint.  Two  days  afterwards  a  slight  fit  occurred,  in  which 
the  child  died. 

The  upper  lobe  of  the  right  lung,  and  many  isolated  lobules  in  the 
left,  were  in  a  state  of  carnification.  The  foramen  ovale,  though  not 
closed,  was  yet  not  widely  open,  while  no  attempt  whatever  seemed  to 
have  been  made  to  close  the  ductus  arteriosus. 

In  this  case,  the  livid  colour  of  the  surface,  often  observed  when  the 
two  sides  of  the  heart  communicate  freely,  was  altogether  absent,  and 
nutrition  seems  for  a  time  to  have  gone  on  well.  At  this  early  period 
in  infantile  life  a  child's  movements  are  but  few  and  slight ;  and,  as  no 
cause  arose  to  disturb  the  equability  of  the  heart's  action,  there  were 
no  paroxysms  of  difficult  breathing,  and  no  symptoms  of  threatening 
suffocation.  The  temperature,  however,  was  but  ill  maintained;  and 
when  the  poison  of  syphilis  had  contaminated  the  blood,  nutrition  lan- 
guished; for  the  circulating  fluid  was  not  only  imperfectly  aerated,  but 
tainted  with  disease ;  the  strength  failed,  the  inspiratory  effort  was  no 
longer  adequate  to  expand  the  lungs,  and  the  patient  died. 

The  third  case  was  that  of  a  puny,  weakly,  backward  little  girl,  who 
came  under  my  notice  at  three  years  old,  when  she  was  suffering  from 
a  severe  attack  of  measles,  with  bronchitis.  It  was  many  months  before 
she  regained  her  health,  and  it  was  during  her  convalescence  that  the 
indications  of  disease  of  the  heart  first  attracted  my  attention.  She 
had  always  been  ailing  from  her  birth,  and  her  extremities  had  habi- 
tually presented  a  deep  blue  colour,  which  at  some  times  was  much  more 
striking  than  at  others.  When  four  years  old,  she  had  become  strong 
and  hearty,  and  very  fat ;  but  even  then  her  finger  nails  had  a  deep 
blue  tinge ;  and  the  same  colour  was  evident,  though  in  a  less  degree, 
about  her  feet,  while  she  always  suffered  much  from  cold.  Occasionally 
she  had  sudden  attacks  of  uneasiness^  which  lasted  for  various  periods, 
were  accompanied  by  complaints  of  great  weariness,  and  of  pain  at  the 
epigastrium ;  and  during  their  continuance  the  hands,  feet,  lips,  and 
inside  of  the  mouth,  turned  of  a  deep  blue  colour.  At  this  time  a  loud 
bruit  accompanied  the  first  sound  of  the  heart,  being  louder  at  the  base 


316  MALFORMATIONS  OF  THE  HEART. 

than  the  apex,  continued  along  the  aorta,  and  heard  over  the  whole  of 
the  chest,  both  in  front  and  behind.  The  child  grew  up,  and  passed 
through  a  very  severe  attack  of  scarlatina,  though  she  nearly  sank 
under  the  exhaustion  which  followed  it.  At  nine  years  old  her  health 
was  very  good,  but  she  was  exceedingly  fat,  and  quite  unequal  to  any 
exertion.  In  going  up  stairs  she  laboured  for  her  breath,  and  her  face 
and  hands  turned  blue,  while  the  natural  colour  of  her  lips  and  ex- 
tremities was  very  livid,  and  her  surface  very  chilly.  When  quite  quiet, 
her  respiration  was  easy,  and  the  sound  of  puerile  breathing  was  heard 
throughout  both  lungs.  Her  pulse  was  about  90,  small  and  feeble,  and 
the  heart's  impulse  weak.  The  results  of  former  auscultations  were 
confirmed,  and  the  bruit  was  ascertained  to  be  continued  along  the 
course  of  the  pulmonary  artery,  as  well  as  along  the  aorta.  The  child 
is  now  fifteen  years  old.  I  often  see  her ;  and  her  condition,  which 
continues  just  the  same,  seems  to  render  it  probable  that,  with  care,  she 
may  reach  the  ordinary  term  of  human  existence. 

And  now,  gentlemen,  in  bringing  this  lecture  of  details  to  a  close,  let 
me  make  my  excuse,  in  better  language  than  my  own,  for  having  to- 
day brought  before  you  mere  isolated  facts,  rather  than  a  complete 
description  of  those  diseases  with  the  study  of  which  we  have  been 
occupied. 

"  The  subjects  of  our  profession,"  says  Dr.  Latham,  "  require  to  be 
treated  summarily  or  in  detail,  according  to  the  degree  of  light  that  is 
brought  to  bear  upon  them  from  a  general  pathological  principle.  If 
you  enter  a  spacious  room  with  a  small  taper,  you  must  carry  it  about 
and  pick  your  way  with  it  into  corners  and  recesses,  and  round  pillars 
and  projections ;  and,  after  all,  you  will  hardly  know  where  you  are, 
and  will  be  lucky  if  you  escape  without  accidents.  But  if  you  enter 
the  same  with  a  bright  burning  lamp,  you  have  only  to  place  it  on  a 
pedestal,  and  then  stand  in  the  midst  and  look  around,  and  then  you 
will  find  all  things,  great  and  small,  near  and  remote,  brought  out 
equally  to  view,  and  will  at  once  understand  and  admire  the  beauty  and 
proportions  of  the  whole  apartment. 

"  So  it  is  with  our  clinical  inquiries.  We  must  deaf  much  in  detail ; 
we  must  note  cases  one  by  one,  while  we  yet  want  a  great  pathological 
principle  which  can  show  their  natural  relations,  and  reconcile  them 
together.  But  once  establish  such  a  principle,  and  it  will  compass  and 
illustrate  perhaps  a  hundred  particulars  at  once,  and  render  their 
minuter  examination  needless  and  superfluous." 


CASES   OF   DISEASE   OF   THE   HEART. 


317 


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DISEASES    OF   THE   ORGANS   OF  DIGESTION   AND   ASSIMILATION.      323 


LECTURE  XXVII. 

Diseases  of  the  Organs  of  Digestion  and  Assimilation. — Peculiarities  of  the  digestive 
organs — they  require  a  peculiar  kind  of  food,  the  milk — composition  of  that  fluid,  its 
adaptation  for  the  nutriment  of  the  infant — changes  in  the  digestive  organs  as  the 
child  grows  older — these  changes  take  place  more  slowly  in  the  human  subject  than 
in  animals. 

Evils  of  giving  other  food  than  the  mother's  milk  until  the  infant  is  old  enough  to  bear 
it — shown  by  the  increased  mortality  it  produces — different  modes  in  which  such  food 
acts  injuriously — appearances  found  in  bodies  of  children  who  have  died  from  imper- 
fect nutrition.  , 

Great  importance  of  infants  being  suckled,  even  for  a  short  time — rules  for  management 
of  children  whose  mothers  are  unable  to  suckle  them — substitutes  for  mother's  milk 
— caution  with  reference  to  occasional  unhealthy  condition  of  cows'  milk. 

We  prefaced  our  investigation  of  the  diseases  of  the  nervous  and 
respiratory  systems  with  an  inquiry  into  the  peculiarities  of  structure 
and  of  function  which  characterize  those  organs  in  early  life.  A  similar 
inquiry  will  not  be  out  of  place  now,  as  preliminary  to  the  study  of  the 
diseases  of  the  organs  of  digestion  and  assimilation,  and  their  depen- 
dencies. 

Man,  when  he  has  attained  to  maturity,  is  able  to  support  his  life, 
and  to  preserve  his  health,  upon  food  of  various  kinds ;  and  the  structure 
of  his  organs  is  such  as  to  enable  him  to  live  upon  an  exclusively  animal 
diet,  or  upon  food  furnished  entirely  by  the  vegetable  kingdom.  We 
know  that  iri  either  case  the  ultimate  elements  from  which  the  body  is 
nourished  are  the  same;  but  that  while  in  the  former  instance  they  are 
furnished  as  it  were  ready  to  hand,  they  have  in  the  latter  to  be  elimi- 
nated by  nature's  chemistry,  through  a  process  which  occupies  much 
time,  and  which  requires  considerable  complexity  in  the  apparatus  that 
effects  it. 

Those  powers,  however,  of  which  the  adult  is  possessed,  belong  in  but 
comparatively  small  measure  to  the  infant.  The  growing  animal,  indeed, 
needs  proportionably  more  food  than  the  adult;  for  not  merely  is  the 
daily  waste  to  be  repaired,  and  that  constant  reproduction  of  the  tissues 
to  be  provided  for  which  is  essential  to  the  maintenance  of  vitality  in  all 
parts  of  the  body,  but  each  day  is  to  bring  with  it  an  increase  in  size  and 
stature.  But  though  in  early  life  an  ample  supply  of  food  is  so  neces- 
sary, yet  the  organs  by  which  it  is  to  be  assimilated,  like  those  which 
have  other  offices  to  perform,  are  at  that  time  frail  and  delicate,  and 
must  not  be  overworked.  Their  development  is  incomplete,  not  in 
strength  only,  but  also  in  form.1  The  peculiarities  which  characterize 
the  digestive  process  in  ruminants,  do  not  begin  till  some  time  after 
birth :  the  fourth  stomach  is  the  only  one  called  into  use  ;  the  others  are 
little  more  than  indicated  in  the  new-born  animal.     In  the  infant,  too, 

1  Many  of  the  facts  mentioned  concerning  the  peculiarities  of  the  digestive  organs  in 
early  life,  are  to  be  found  iu  Burdach's  Physiologic,  vol.  iii.  \  512  to  540  ;  and  in  Schultz's 
Essay,  Ueber  den  Akt  des  Erbrechens,  &c.  in  the  Analekten  ueber  Kinderkrankheiten, 
vol.  ii.  Heft.  vi.  p.  G2. 


324  PECULIARITIES   OF   THE   DIGESTIVE   ORGANS   IN   INFANCY. 

the  form  of  the  digestive  organs,  as  well  as  their  feeble  muscularity, 
shows  them  to  be  unsuited  for  food,  which  needs  to  pass  through  a  long 
process  of  preparation  within  the  body  before  it  becomes  fitted  to  nourish 
it.  The  shape  of  the  human  stomach  in  the  first  month  of  existence 
approaches  that  which  it  retains  through  life  in  the  carnivora,  in  whom 
the  process  of  digestion  is  more  simple  than  in  any  other  mammalia. 
It  is  long,  but  little  curved,  growing  narrower  toward  either  end,  where 
it  passes  into  the  oesophagus  on  the  one  hand,  and  into  the  intestine  on 
the  other.  Its  small  curvature  is  but  little  arched,  and  approaches 
nearly  to  a  straight  line ;  the  large  curvature  is  but  slightly  developed, 
and  runs  almost  parallel  with  the  other, — characteristics  which  are  all 
found  in  the  stomach  of  carnivorous  animals.  Compare  with  this  the 
form  of  the  stomach  in  the  adult.  It  is  altogether  more  rounded :  the 
oesophagus  no  longer  enters  at  its  left  extremity,  but  nearly  midway 
between  that  point  and  the  pylorus.  The  pylorus  itself  is  drawn  back 
towards  the  cardia,  and  the  two  orifices  are  thus  brought  near  to  each 
other  :  hence  the  small  curvature  is  very  short ;  the  great  curvature  of 
considerable  extent,  forming  not  merely  the  whole  under  part  of  the 
circumference  of  the  stomach,  but  likewise  bounding  the  whole  of  that 
pouch  which  is  situated  beyond  its  cardiac  orifice.  Besides  this,  too, 
the  transition  from  the  pylorus  to  the  intestine  is  gradual  in  the  child, 
while  in  the  adult  the  demarcation  between  stomach  and  intestine  is  well 
marked.  The  result  of  all  this  is,  that  in  the  adult,  who  is  an  omnivo- 
rous animal,  the  stomach  presents  a  form  not  unlike  that  which  it  has 
in  some  of  the  rodents — as  the  rat  and  the  rabbit;  and  that  the  food,  in 
the  course  of  digestion,  undergoes  somewhat  of  a  rotatory  motion,  not 
the  simple  onward  movement  which  is  communicated  to  it  in  the  stomach 
of  the  carnivora.  The  stomach  of  the  adult,  then,  is  framed  to  act  upon 
substances  which  may  require  some  time  for  their  digestion,  while  that 
of  the  infant  is  ill  suited  to  retain  matters  long  within  it,  and  its  small 
size  unfits  it  for  receiving  much  at  once.  If,  therefore,  the  food  given 
to  an  infant  be  such  as  it  can  digest  with  facility,  it  soon  passes  out  of 
the  stomach,  and  the  infant  speedily  seeks  for  more.  Nor  are  these 
arrangements  calculated  for  the  rapid  digestion  of  easily  assimilated 
food,  confined  to  the  stomach  of  the  infant,  but  the  form  and  proportions 
of  the  intestines  correspond  thereto  :  the  small  intestine  is  of  relatively 
shorter  length  than  in  the  adult ;  the  large  intestine  of  smaller  calibre ; 
the  caecum  less  developed ;  whilst  the  peristaltic  action  of  the  bowels  is 
more  rapid  than  in  later  life ;  excrementitious  matters  are  quickly 
expelled,  and  the  healthy  infant  passes  three  or  four  evacuations  in  the 
twenty-four  hours. 

But  while  the  digestive  organs  of  the  young  of  all  mammiferous 
animals  are  thus  adapted  to  ensure  the  rapid  performance  of  their  func- 
tions, and  to  provide  for  the  quick  as  well  as  for  the  complete  nutrition 
of  the  body,  the  question  naturally  suggests  itself,  where  shall  that  food 
be  found,  which,  while  it  yields  the  necessary  sustenance,  is  yet  so  easily 
assimilated  as  not  to  require  powers  of  which  the  delicate  organs  of  the 
young  are  destitute  ?  We  should  search  in  vain  through  the  animal  and 
vegetable  kingdom  for  any  substance  completely  fulfilling  these  condi- 


MILK   THE   PROPER   ALIMENT   FOR   THE   YOUNG.  325 

tions,  had  not  nature  supplied  the  want,  and  given  to  every  mother  the 
means  of  herself  nourishing  her  young. 

Milk,  the  proper  aliment  of  the  young,  expressly  prepared  for  it  within 
its  mother's  organism,  contains,  ready  combined,  all  those  elements 
which  are  necessary,  whether  for  its  growth  or  for  the  maintenance  of 
its  proper  temperature,  by  serving  as  materials  for  respiration.  The 
mean  of  14  analyses  of  human  milk,  by  the  late  Professor  Simon,  of 
Berlin,1  yields  the  following  result: — It  is  composed  of 

Water         .         .         .        883-6 
Solid  matters      .         .        1164 

100  parts  of  these  solid  constituents  are  made  up  of 

Casein         .         .         .  31-2 

Butter         .         ...  23-0 

Sugar  of  milk,  and  extractive 

matter     .         .         .  43*8 

Incombustible  salts      .  3-0 


100-0 


How  small  must  be  the  effort  needed  to  effect  the  assimilation  of  this 
fluid  !  The  chief  of  its  solid  constituents,  the  casein,  differs  little,  if  at 
all,  from  the  albumen  of  the  blood,  while  in  combination  with  it  is  a 
considerable  quantity  of  the  phosphate  of  lime — a  salt  that  enters  largely 
into  the  cornposition  of  the  bones.  Among  its  other  components  we 
find  butter  and  sugar,  the  former  of  which  probably  in  part  contributes 
to  the  formation  of  the  fat  which  is  so  abundantly  deposited  in  the 
healthy  infant,  while  the  remainder  of  it  supplies  materials  for  the 
generation  of  heat,  by  being  resolved,  together  with  the  saccharine 
matter,  into  its  ultimate  elements  of  carbonic  acid  and  water.  This 
food,  too,  is  not  merely  suitable  for  the  infant  soon  after  birth,  but  it 
continues  to  be  the  aliment  most  proper  for  it  for  many  months ;  the 
casein  increasing  in  quantity  as  the  infant  grows  older,  and  the  demand 
for  materials  to  maintain  its  growth  increases. 

By  degrees  the  stomach  alters  in  form :  its  muscularity  increases ; 
the  powers  of  the  digestive  organs  become  greater,  and  the  child  becomes 
able  to  derive  support  from  food  in  which  the  nutritive  principles  are 
not  presented  in  so  simple  a  form  as  in  the  milk.  At  the  ninth  month 
teeth  begin  to  appear ;  the  first  clear  evidence  of  those  changes  which 
nature  is  working  in  the  organism,  and  the  indication  that  before  very 
long  the  child  will  be  able  entirely  to  dispense  with  that  elaborately 
prepared  nourishment  which  it  has  hitherto  derived  from  its  mother. 
In  the  human  subject  the  process  of  dentition  not  only  begins  late,  but 
it  goes  on  slowly ;  the  first  molar  tooth  is  seldom  cut  before  the  com- 
mencement of  the  second  year :  dentition  is  not  concluded  till  its  end. 
Nature's  object  in  the  laws  by  which  she  governs  the  brute  creation, 

1  The  statements  with  reference  to  the  chemistry  of  the  milk  are  taken  from  Sherer's 
article  "  Milch,"  in  Wagner's  Handworteerbuch  der  Physiologie,  Part  10. 


826  CHANGES   IN   THE   DIGESTIVE   ORGANS   VERY   GRADUAL. 

appears  to  be,  to  fit  the  young  animals  as  soon  as  possible  to  provide 
for  themselves,  and  to  shorten  the  period  during  which  they  must 
depend  for  sustenance  on  their  mother ;  and,  therefore,  they  begin  to 
cut  their  teeth  much  sooner,  and  the  process  is  completed  within  a 
much  shorter  time,  than  in  the  infant.  Young  rabbits  are  always 
provided  with  two  teeth  when  born,  and  the  others  make  their  appear- 
ance within  ten  days ;  in  the  different  ruminants,  the  teeth  have  either 
begun  to  appear  before  birth,  or  they  show  themselves  a  few  days 
afterwards,  and  in  either  case  dentition  is  completed  within  the  fiist 
month ;  and  in  dogs  and  cats  during  the  first  ten  weeks  of  existence. 

For  the  difference  in  this  respect  between  the  lower  animals  and 
man,  it  seems  to  me  that  a  moral  reason,  not  altogether  visionary,  may 
be  assigned.  The  young  animal  has  to  learn  nothing  more  than  how 
to  apply  those  instincts  with  which  Almighty  power  has  endowed  it  for 
its  own  support  and  the  perpetuation  of  its  species.  But  the  infant  is 
to  be  trained  to  become  a  man  :  its  moral  as  well  as  its  physical  nature 
is  to  be  cultivated :  parental  influence  is  to  be  the  means  of  doing  this  ; 
and  Providence  may  have  wisely  determined  that  the  infant  shall  for 
months  be  dependent  on  its  mother  for  support,  in  order  that  her 
instinctive  feelings  may  lay  the  firm  foundation  of  that  love  which 
causes  her  to  cling  to  her  little  one  with  a  fondness  that  surpasses  all 
other  affection,  and  which  gives  her  the  patience,  the  gentleness,  the 
untiring  energy,  that  make  her  the  child's  best  guardian,  friend,  and 
teacher,  during  its  early  years. 

But  whether  it  is  right  or  wrong  to  seek  in  something  higher  than 
the  material,  for  the  reasons  of  this  physical  law,  it  yet  is  a  law,  and 
one  which  cannot  be  violated  with  impunity.  The  infant  whose  mother 
refuses  to  perform  towards  it  a  mother's  part,  or  who,  by  accident, 
disease,  or  death,  is  deprived  of  the  food  that  nature  destined  for  it, 
too  often  languishes  and  dies.  Such  children  you  may  often  see,  with 
no  fat  to  give  plumpness  to  their  limbs, — no  red  particles  in  their  blood 
to  impart  a  healthy  hue  to  their  skin, — their  face  wearing  in  infancy 
the  lineaments  of  age, — their  voice  a  constant  wail, — their  whole  aspect 
an  embodiment  of  woe.  But  give  to  such  children  the  food  that  nature 
destined  for  them,  and  if  the  remedy  do  not  come  all  too  late  to  save 
them,  the  mournful  cry  will  cease,  the  face  will  assume  a  look  of  con- 
tent, by  degrees  the  features  of  infancy  will  disclose  themselves,  the 
limbs  will  grow  round,  the  skin  pure  red  and  white ;  and  when,  at 
length,  we  hear  the  merry  laugh  of  babyhood,  it  seems  almost  as  if  the 
little  sufferer  of  some  weeks  before  must  have  been  a  changeling,  and 
this  the  real  child  brought  back  from  fairy-land. 

Much  care,  much  patience,  judicious  management  in  all  respects, 
may,  indeed,  counteract  the  otherwise  inevitable  evils  that  result  from 
the  attempt  to  bring  up  infants  by  hand.  The  statement,  however,  . 
just  made  with  reference  to  the  hazard  of  such  an  experiment,  and  to 
the  evil  consequences  that  almost  of  necessity  attend  it,  is  by  no  means  t 
overcharged.  M.  Villerme,  one  of  the  most  distinguished  statisticians 
of  France,  has  compared  the  results  of  the  two  systems  as  followed  in 
three  of  the  principal  foundling  hospitals  in  that  country.1     At  Lyons, 

1  De  la  Mortality  des  Enfans  Trouve's,  in  the  Annalcs  d' Hygiene,  vol.  xix.  p.  47.    Fur- 


EVILS   OF   OTHER   FOOD   THAN   THE   MOTHER'S    MILK.  327 

each  infant,  on  its  reception,  is  given  into  the  charge  of  a  wet  nurse, 
and  its  stay  in  the  hospice  does  not  exceed  a  very  few  days,  after  which 
it  is  sent  to  he  nursed  in  the  country.  At  Rheims,  the  stay  of  the 
infant  in  the  hospice  is  equally  short ;  hut  neither  while  there,  nor 
afterwards  when  at  nurse  in  the  country,  is  it  brought  up  at  the  breast. 
At  Paris,  the  stay  of  the  children  in  the  hospice  is  often  very  much 
longer ;  but  they  are  usually,  though  not  invariably,  suckled  by  wet 
nurses.  The  mortality  under  1  year  of  the  children  admitted  into  these 
institutions  is — 

At  Lyons. 33*7  per  cent. 

„    Paris 50*3        „ 

„    Rheims 63*9        „ 

These  results  need  no  comment,  and  render  it  almost  unnecessary  to 
adduce  any  farther  evidence  of  the  dangers  that  are  inseparable  from 
the  attempt  to  bring  up  infants  on  artificial  food.  One  more  illustra- 
tion of  the  fact,  however,  may  be  adduced  from  the  work  of  a  benevolent 
ecclesiastic,  M.  Gaillard,  on  the  foundling  hospitals  of  France.  He 
observes — 

"At  Parthenay,  in  the  department  of  Deux-Sevres,  of  153  found- 
lings, 54  died  between  the  ages  of  one  day  and  twelve  months,  or  35 
per  cent.,  which  is  a  higher  proportion  than  that  presented  at  Poitiers. 

At  X ,  of  244  new-born  infants,  197,  or  80  per  cent.,  had  died  by 

the  end  of  the  first  year.  Struck  by  the  enormous  difference  between 
this  rate  of  mortality  and  that  afforded  by  the  hospices  at  Poitiers  and 
Parthenay,  I  determined  to  investigate  its  cause.  I  ascertained  that 
in  this  hospice  as  much  attention  is  paid  to  the  children,  and  the  nurses 
are  under  as  strict  oversight,  as  at  Poitiers  and  Parthenay.     But  at 

X none  of  the  children  are  suckled,  but  all  are  fed ;  and  the  reason 

assigned  for  so  doing  is  the  fear  of  infecting  the  nurses  with  syphilis. 
Be  this  as  it  may,  I  have  been  assured  by  many  persons  connected  with 
the  institution,  that  the  fearful  mortality  just  mentioned  can  be  attri- 
buted to  no  other  cause  than  the  practice  of  not  suckling  the  children. 
The  officers  of  the  hospice  have  tried  all  means  to  remedy  this  evil,  but 
neither  their  own  efforts,  nor  those  of  some  most  excellent  female 
assistants,  have  been  of  the  slightest  service ;  and  the  only  measure  by 
which  they  could  reduce  the  mortality,  was  the  having  recourse  to  suck- 
ling the  children  by  wet  nurses."1 

It  can  hardly  be  necessary  to  say,  that  these  statements  are  not  to 
be  taken  as  representing  the  ordinary  mortality  among  infants  brought 
up  by  hand,  since  many  causes  will  suggest  themselves  to  you  as  con- 
curring to  render  the  life  of  foundlings  especially  precarious.  Neither, 
indeed,  is  the  whole  of  the  mortality  among  other  children  who  have 
been  deprived  of  the  mother's  milk  to  be  attributed  to  the  food  which 

ther  information  on  this  and  other  allied  subjects  will  be  found  in  a  review  of  the  works 
of  Terme,  Monfalcon,  and  others,  on  the  Foundling  Hospitals  of  France,  published  by 
the  author  in  the  British  and  Foreign  Medical  Preview  for  April,  1842. 

1  Recherches  surles  Enfans  Trouvds,  &c.  parl'Abb^  A.  H.  Gaillard,  8vo.  p.  166.  Paris, 
1337. 


328  INFANTILE    MORTALITY   FROM   ARTIFICIAL   FEEDING. 

is  substituted  for  it ;  but  in  many  cases,  if  the  mother  do  not  suckle 
her  infant,  she  delegates  to  another  the  performance  of  her  other 
maternal  duties,  and  the  baby  is  left  to  languish  in  the  house  of  a 
stranger.  That  this  cause  is  very  influential  in  producing  a  high  rate 
of  mortality  among  infants,  appears  from  the  fact  mentioned  by  M. 
Benoiston  de  Chateauneuf,1  that  while  among  children  suckled  by  their 
mothers  only  18.36  per  cent,  die  within  a  year  after  their  birth,  29  per 
cent,  of  those  put  out  to  wet-nurse  die  during  the  same  period. 

It  is  not  enough,  however,  for  us  to  know  that  food  other  than  the 
mother's  milk  is  injurious  to  the  young  infant ;  but  it  behoves  us,  both 
as  physiologists  and  as  physicians,  to  push  our  inquiries  further,  to 
ascertain  as  far  as  possible  the  means  by  which  this  injurious  effect  is 
produced,  and  to  determine  what  organs  of  the  body  suffer  most 
severely,  and  the  mode  in  which  they  are  affected.  Unfortunately,  the 
information  which  I  am  able  to  give  you  on  these  points  is  much  less 
definite  than  I  could  wish  ;  for  the  evils  that  result  from  improper  food 
in  infancy  do  not,  like  some  diseases,  arrest  attention  by  their  alarming 
symptoms,  or  by  their  rapidly  fatal  result,  and  hence  they  have  received 
less  than  their  due  share  of  notice. 

If  improper  food  be  given  to  an  infant,  the  contractions  of  the 
stomach  are  in  general  speedily  excited,  and  the  food  is  rejected. 
Owing  to  the  form  of  the  stomach  in  infancy,  and  the  position  which  it 
occupies  in  the  abdomen — approaching  to  the  perpendicular  rather 
than  the  transverse — vomiting  is  then  attended  with  little  distress :  the 
child  eructates  the  food  almost  without  effort,  and  in  a  few  minutes 
seems  well  again.  This  eructation  of  a  portion  of  its  food  may  indeed 
be  noticed  even  in  infants  at  the  breast,  who  have  either  sucked  more 
than  their  stomach  can  conveniently  hold,  or  whose  digestive  powers 
are  temporarily  weakened  by  some  trivial  ailment.  But  the  hint  which 
nature  gives  is  too  often  thrown  away  on  those  who  have  the  charge  of 
the  infant.  Food  of  the  same  kind  is  given  again,  perhaps  in  smaller 
quantity,  or  with  some  slight  difference  in  its  mode  of  preparation,  and 
part,  or  the  whole  of  it,  is  now  retained.  The  shape  of  the  organ,  how- 
ever, does  not  allow  of  substances  remaining  long  within  it ;  and  hence 
those  which  need  much  time  for  their  digestion,  if  not  rejected  by 
vomiting,  pass  the  pylorus  while  that  process  is  but  half  completed. 
Unfortunately  the  farinaceous  articles  of  food  which  are  so  often 
selected,  on  account  of  their  supposed  lightness,  as  fit  to  form  the 
almost  exclusive  diet  of  infants,  belong  to  the  class  of  substances  that 
are  assimilated  with  difficulty ;  so  that  a  large  proportion  of  the  con- 
tents of  the  stomach,  in  the  young  child  brought  up  by  hand,  enter  the 
duodenum  in  a  state  wholly  unfit  to  be  acted  on  by  the  bile.  The 
intestines  become  irritated  by  these  undigested  matters ;  and,  in  the 
effort  to  get  rid  of  them,  diarrhoea  is  excited ;  while,  if  not  speedily 
expelled,  they  pass  into  a  state  of  fermentation  or  putrefaction,  and 
thus  produce  those  horribly  offensive  evacuations  which  are  frequently 
voided  by  children  under  these  circumstances. 

It  would  be  natural  to  expect  that  a  child  should  lose  flesh  and 
strength,  even  if  the  food  given  to  it  were  no  otherwise  objectionable 

1  Considerations  sur  les  Enfans  Trouvds,  8vo.  p.  57.    Paris,  1824. 


INJURIOUS   EFFECTS   OF   ARTIFICIAL   FEEDING   EXPLAINED.  329 

than  as  being  difficultly  digested.  The  stomach,  indeed,  becomes  in 
time  more  accustomed  to  it ;  and  it  has  been  stated1  that  its  form  some- 
times undergoes  a  change  by  which  it  approximates  to  that  of  the 
stomach  in  the  adult,  or  even  in  the  herbivorous  quadruped,  and  thus 
becomes  able  to  retain  food  within  it  for  a  longer  time.  But  even 
though  this  change  took  place  to  a  much  greater  degree  than  there 
seems  reason  for  believing  to  be  the  case,  the  evil  of  such  a  diet  would 
not  be  half  remedied ;  for  not  only  are  the  sago,  arrow-root,  or  gruel, 
with  which  the  child  is  fed,  in  themselves  less  easy  of  digestion  than 
the  milk,  which  is  its  proper  aliment ;  but,  when  reduced  to  their  ulti- 
mate elements,  they  present  essential  differences  from  it,  and  differ- 
ences by  which  they  are  rendered  so  much  the  more  inapt  to  nourish 
the  body  during  the  period  of  its  most  active  development  and  growth. 
It  would  be  out  of  place  to  enter  here  into  minute  details  with  reference 
to  the  physiology  of  digestion,  or  the  composition  of  different  articles 
of  food,  in  order  to  illustrate  this  subject ;  neither,  indeed,  is  it  neces- 
sary to  do  so.  You  are  aware  that  physiological  and  chemical  research 
has  proved  that  food  has  to  answer  two  distinct  purposes  in  the 
organism :  the  one  to  furnish  materials  for  the  growth  of  the  body  ;  the 
other  to  afford  matter  for  the  maintenance  of  its  temperature  ;  and 
that  life  cannot  long  be  supported,  except  on  a  diet  in  which  the 
elements  of  nutrition  and  the  elements  of  respiration  bear  a  certain 
proportion  to  each  other.  Now  in  milk,  the  proper  food  of  infants,  the 
elements  of  the  former  are  to  those  of  the  latter,  according  to  the 
approximative  estimate  of  an  English  chemist,3  in  the  proportion  of  1 
to  2 ;  while  in  arrow-root,  sago,  and  tapioca,  they  are  only  as  1  to  26, 
and  even  in  wiieaten  flour  only  as  1  to  7.  If  to  this  we  add  the  absence 
in  these  substances  of  the  oleaginous  matters  which  the  milk  contributes 
to  supply  the  body  with  fat  (and  which  can  be  eliminated  from  farina- 
ceous substances  only  by  a  conversion  of  their  elements,  to  which  the 
feeble  powers  of  digestion  in  early  life  are  not  equal,)  and  the  smaller 
quantity,  and,  to  a  certain  extent,  the  different  kind  of  the  salts  which 
they  contain,  it  becomes  at  once  apparent  that  by  such  a  diet  the 
health,  if  not  the  life,  of  the  infant  must  inevitably  be  sacrificed.  The 
body  wastes  most  rapidly ;  for  it  is  forced  from  its  own  tissues  to  supply 
the  nitrogenous  elements  essential  to  the  maintenance  of  life,  and 
which  its  food  contains  in  far  too  scanty  a  proportion.  Every  organ  in 
the  body  contributes  to  the  general  support,  and  life  is  thus  prolonged, 
if  no  kind  disease  curtail  it,  until  each  member  has  furnished  all  that  it 
can  spare,  and  then  death  takes  place  from  starvation ;  its  approach, 
indeed,  having  been  slower,  but  the  suffering  which  preceded  it  not 
therefore  less,  than  if  all  food  had  been  withheld. 

I  have  dwelt  at  length  upon  this,  which  is  the  most  frequent  cause  of 
the  atrophy  of  new-born  children :  but  similar  effects  are  produced 
when,  from  any  other  reason,  an  infant  is  imperfectly  nourished, 
whether,  as  sometimes  occurs,  the  mother's  milk  is  so  deteriorated  as 
to  be  unsuitable  for  its  support;  or  whether,   as  often  happens,  the 

1  Schultz,  loc.  cit.  p.  74-5. 

2  Dr.  R.  D.  Thomson,  On  the  Relation  between  the  Constituents  of  the  Food  and  the 
Systems  of  Animals,  in  vol.  xxix.  of  the  Medico-Chirurgical  Transactions. 


330  IMPERFECT   NUTRITION   OF   INFANTS. 

child  having  been  weaned  prematurely,  its  digestive  organs  are  unequal 
to  the  task  of  assimilating  the  food  that  has  been  substituted  for  the 
mother's  milk.  In  both  cases  the  abdominal  viscera  become  disordered, 
nutrition  is  ill  performed,  and  the  child  falls  into  a  state  of  atrophy. 

On  examining  after  death  the  bodies  of  children  who  have  died  under 
these  circumstances,  the  complete  absorption  of  all  the  fat,  and  the 
removal  of  much  even  of  the  cellular  tissue,  is  the  point  that  first 
attracts  our  notice.  The  thoracic  viscera  present  no  unnatural  appear- 
ance, unless  it  be  that  large  portions  of  the  lungs  are  sometimes  found 
in  a  state  of  collapse.  There  is  also  seldom  anything  unnatural  in  the 
condition  of  the  liver,  except  the  congested  state  of  the  organ,  the 
vessels  of  which,  being  often  loaded  with  venous  blood,  form  a  marked 
contrast  to  the  generally  anaemic  appearance  of  the  other  viscera. 
The  gall-bladder  is  usually  full  of  bile,  probably  because,  as  in  the  case 
of  persons  who  have  died  of  inanition,  the  empty  stomach  has  long 
ceased  to  stimulate  it  to  contraction  by  its  movements.  The  stomach 
and  small  intestines  are  in  general  nearly  empty  ;  the  fundus  of  the 
stomach  is  sometimes  found  more  or  less  softened, — a  condition,  the 
occurrence  of  which  after  death  is  probably  favoured  by  the  tendency 
of  those  kinds  of  food  that  are  usually  given  in  early  life,  to  pass  into 
a  state  of  fermentation,  in  the  course  of  which  an  acid  is  produced 
which  is  capable  of  dissolving  the  animal  tissues.  In  some  instances  in 
which  children  have  been  fed  on  an  exclusively  farinaceous  diet,  the 
mucous  membrane  even  low  down  in  the  intestines,  has  been  found 
covered  with  a  thin  coating  of  starch,  which  presented  the  characteristic 
blue  colour  when  tested  with  iodine.1  The  intestines  are  generally 
pale,  though  with  patches  intermingled  of  a  red  or  dark  grey  colour  ; 
besides  which  small  circumscribed  spots  of  bright  vascularity  are  some- 
times interspersed  through  the  small  intestines,  being  especially  evident 
at  their  upper  part.  Peyer's  glands  usually  appear  much  more  promi- 
nent than  is  natural ;  sometimes  they  are  of  a  brighter  red  than  the 
surrounding  intestine,  and  somewhat  swollen,  and  sometimes  they  are 
of  a  large  grey  tint,  and  present  a  singular  punctated  appearance.  In 
the  large  intestines  there  is  also  sometimes  a  remarkable  development 
of  the  solitary  glands,  the  dark  orifice  of  which  renders  them  very 
evident;  and  in  a  few  instances  they  become  still  more  apparent,  from 
the  mucous  membrane  immediately  around  each  presenting  a  dark  grey 
colour.  The  appearances  in  short,  are  those  of  general  inanition, 
coupled  with  the  signs  of  irritation  or  inflammation  of  the  whole 
secreting  apparatus  of  the  intestinal  canal.2 

The  full  consideration  of  every  question  connected  with  the  imperfect 
nutrition  of  infants  would  require  little  else  than  a  complete  treatise  on 

1  According  to  some  experiments  by  M.  Guillot,  of  Paris,  referred  to  by  Dr.  Stewart, 
of  New  York,  in  a  paper  republished  from  an  American  Journal  in  the  Dublin  Medical 
Journal,  March,  1845. 

2  This  account  of  the  post-mortem  appearances  observed  in  infants  who  have  been  im- 
perfectly nourished,  is  not  merely  borne  out  by  the  very  interesting  paper  of  MM.  Fried- 
leben  and  Fleisch,  in  Vol.  v.  of  the  Zeitschvift  fiir  rationelle  Medicin,  Heidelberg,  1846; 
but  receives  a  remarkable  illustration  in  the  recent  work  of  M.  Bednar,  physician  to  the 
Foundling  Hospital  at  Vienna.  The  observations  of  the  former  gentlemen  are  founded 
on  the  examination  of  lilteen  infants,  all  of  whom  were  under  one  year  old,  who  were 


SUCKLING   IMPORTANT,    EVEN    THOUGH   ONLY   FOR   A   SHORT   TIME.     331 

the  dietetics  of  early  life.  In  these  lectures  I  can  aim  at  nothing 
more  than  to  bring  before  your  notice  a  few  points  of  the  greatest 
importance. 

Although  it  is  very  desirable  that  for  the  first  six  months  of  their 
existence  children  should  derive  their  support  entirely  from  their 
mother,  and  that  until  they  are  a  year,  or  at  least  nine  months  old, 
their  mother's  milk  should  form  the  chief  part  of  their  food,  yet  many 
circumstances  may  occur  to  render  the  full  adoption  of  this  plan  im- 
practicable. In  some  women  the  supply  of  milk,  although  at  first 
abundant,  yet  in  the  course  of  a  few  weeks  undergoes  so  considerable  a 
diminution  as  to  become  altogether  insufficient  for  the  child's  support ; 
while  in  other  cases,  although  its  quantity  continues  undiminished,  yet 
from  some  defect  in  its  quality  it  does  not  furnish  the  infant  with 
proper  nutriment.  Cases  of  the  former  kind  are  not  unusual  in  young, 
tolerably  healthy,  but  not  robust  women ;  while  instances  of  the  latter 
are  met  with  chiefly  among  those  who  have  given  birth  to  several 
children,  whose  health  is  bad,  or  whose  powers  are  enfeebled  by  hard 
living  or  hard  work.  The  children  in  the  former  case  thrive  well 
enough  for  the  first  six  weeks  or  two  months ;  but  then,  obtaining  the 
milk  in  too  small  a  quantity  to  meet  the  demands  of  their  rapidly 
growing  organism,  they  pine  and  fret,  they  lose  both  flesh  and  strength, 
and  unless  the  food  given  to  supply  their  wants  be  judiciously  selected, 
their  stomach  and  bowels  become  disordered,  and  nutrition,  instead  of 
being  aided,  is  more  seriously  impaired.  If,  however,  a  healthy  wet 
nurse  be  employed  to  supply  the  mother's  inability  to  nourish  her  child, 
its  health  will  soon  return ;  and  by  the  sacrifice  of  the  infant  of  the 
poor  woman,  the  offspring  of  the  wealthy  will  be  preserved.  But  many 
circumstances  besides  those  moral  considerations  which  should  never  be 
forgotten  before  the  determination  is  formed  to  employ  a  wet  nurse, 
may  put  this  expedient  out  of  the  question ;  and  it  becomes,  therefore, 
our  duty  to  inquire  what  course  a  mother  should  pursue,  who  has  learnt 
by  experience  that  she  is  unable  to  suckle  her  child  for  more  than  a 
very  short  period. 

Knowing  the  attempt  to  rear  her  child  entirely  at  the  breast  to  be 
vain,  the  mother  may  in  such  a  case  naturally  be  tempted  to  bring  it  up 
by  hand  from  the  very  first.     But,  how  short  soever  the  period  may  be 

brought  up  either  exclusively,  or  in  great  measure,  on  artificial  food,  and  who  died,  after 
long-continued  illness,  in  a  state  of  atrophy,  or  else  sank  rapidly  under  profuse  watery 
diarrhoea.  In  cases  of  the  former  class,  a  state  regarded  by  the  writers  as  the  result  or 
chronic  inflammation  of  Peyer's  glands  was  the  chief  morbid  appearance  ;  while  in  those 
instances  where  death  took  place  rapidly,  a  swollen  and  congested  condition  of  the  same 
bodies,  betokening,  as  they  believe,  their  recent  inflammation,  was  almost  always  pre- 
sent. They  found,  too,  that  in  all  these  cases  the  disease  of  the  colon  was  comparatively 
slight,  and  evidently  secondary  to  the  more  serious  changes  in  the  small  intestine.  Dr. 
Bednar's  patients  were  all  under  three  months, — many  only  a  few  days  old, — partly 
suckled  by  women,  each  of  whom  had  several  nurslings,  partly  fed  on  artificial  food. 
As  might  be  anticipated,  the  mortality  is  high,  and  of  such  almost  uniform  occurrence 
is  a  swollen  condition  of  the  mesenteric  and  Peyerian  glands,  and  even  of  the  solitary 
glands  of  the  lai'ge  intestines,  that,  when  treating  of  diarrhoea,  he  speaks  of  them  as 
conditions  of  no  sort  of  importance  ;  and  concerning  the  last  expresses  the  opinion  that 
it  is  to  be  regarded  as  a  physiological  rather  than  a  pathological  occurrence.  No  more 
striking  comment  could  be  written  on  the  mischiefs  and  the  dangers  of  artificial  feeding 
of  infants.  See  pp.  37  and  88  of  Bednar's  Krankheiten  der  Neugebornen,  &c.  8vo.  Wien., 
1850. 


332 


SUBSTITUTE   FOR   THE   MOTHER  S   MILK. 


during  which  the  mother  is  ahle  to  suckle  her  child,  it  is  very  desirable 
that  she  should  nurse  it  during  that  period,  and  also,  that  her  milk 
should  then  constitute  its  only  food.  For  the  first  four  or  five  days 
after  the  infant's  birth  the  milk  possesses  peculiar  qualities,  and  not 
merely  abounds  in  fatty  and  saccharine  matters,  but  presents  its  casein 
in  a  more  easily  assimilable  form  than  subsequently.1  It  afterwards 
loses  these  characteristics  ;  but  still,  during  the  first  few  weeks  of  life, 
it  contains  casein  in  smaller  quantities  than  enter  into  its  composition 
at  a  later  period.  The  secretion,  in  short,  is  especially  adapted  to  the 
feeble  powers  of  the  digestive  organs  soon  after  birth :  and  hence  the 
difficulty  of  providing  any  good  substitute  for  it  is  greater  in  proportion 
to  the  tender  age  of  the  infant,  while  art  often  imitates  but  ill  that 
gradual  increase  of  the  casein,  by  which  the  main  element  of  the 
infant's  sustenance  is  made  to  bear  a  constant  proportion  to  the  de- 
mands of  its  daily  growth. 

The  same  course  of  conduct  would  be  proper  in  the  case  of  women 
whose  milk  is  of  so  poor  a  quality  that  their  infants  do  not  thrive  upon 
it,  since,  though  its  deficiency  in  casein  may  render  it  unfit  for  the  per- 
manent support  of  the  child,  yet  that  circumstance  will  not  prove  pre- 
judicial to  it  during  the  first  few  weeks  of  its  existence. 

In  both  of  these  cases,  however,  it  is  only  for  a  season,  and  usually 
a  very  brief  season,  that  the  mother  is  able  to  suckle  her  infant  with 
advantage ;  while  instances  are  by  no  means  rare  in  which  the  import- 
ant question  of  the  best  substitute  for  the  mother  s  milk  has  to  be 
answered  within  a  few  hours  after  the  infant's  birth.  It  is  obvious  that 
the  more  nearly  the  substitute  that  we  select  approaches  to  the  cha- 
racter of  the  mother's  milk,  the  greater  will  be  the  prospect  of  the 
attempt  to  rear  the  infant  upon  it  proving  successful.  Discarding, 
therefore,  all  those  preparations  of  arrow-root,  flour,  or  biscuit  powder, 
in  which  the  vulgar  repose  such  confidence,  we  shall  not  need  any 
laboured  argument  to  convince  us,  that  in  the  milk  of  some  other  animal 
we  shall  be  likely  to  find  the  infant's  most  appropriate  food.  You  will 
perceive,  however,  by  the  subjoined  table,  that  there  are  many  important 

Table  shewing  the  Composition  of  the  Milk  in  Man  and  in  various  Animals. 


In  Man 

100  parts  contain — 

100  parts  of  the  solid  constituents  contain — 

Fluid. 

Solids. 

Casein. 

Butter. 

Sugar  and 
Extractive 
Matters. 

Salts. 

883.6 
842.0 

907.0 
865.0 
856.2 

116.4 
158.0 

93.0 
134.0 
143.8 

31.2 
42.1 

18.0 
41.1 
31.2 

23.0 
28.1 

13.2 

28.0 
29.2 

43.8 
23.9 

2.0 
5.7 

"  the  Cow 

"  "    Ass 

"   "     Goat 

68.5 

30.0 

34.7               4.7 

"  "     Ewe 

1  See  on  this  subject  a  very  interesting  paper  by  Mr.   Moore  of  Dublin,  On  the  Coa- 
gulability of  Human  Milk,  in  Dublin  Journal  of  Medical  Sciences,  May,  1849. 


SUBSTITUTE   FOR   THE    MOTHER'S    MILK.         *  333 

differences  between  the  milk  of  all  the  domestic  animals  and  of  the 
human  female  ;  while  the  infant  who  is  fed  upon  the  milk  of  any  of 
them,  loses  those  advantages  which,  when  it  is  suckled  by  its  mother, 
result  from  the  gradual  change  that  takes  place  in  the  proportion  of  its 
constituents  as  the  infant  advances  in  age. 

The  expense  of  asses'  milk,  which,  from  the  small  quantity  of  casein 
that  it  contains,  is  especially  fitted  for  young  or  delicate  infants,  unfor- 
tunately prevents  it  being  generally  employed ;  and  in  the  majority 
of  instances  in  which  children  are  brought  up  by  hand,  cows'  milk  is 
used,  as  being  the  most  easily  procured.  For  the  first  month  or  five 
weeks,  however,  it  is  very  desirable  that  the  asses'  milk  should  be  given, 
and  that  cows'  milk  should  not  be  substituted  for  it,  until  the  first  dan- 
gers of  the  experiment  of  bringing  an  infant  up  by  hand  have  been 
surmounted.  In  order  to  make  up  for  the  deficiency  of  oily  matter  in 
the  asses'  milk,  the  suggestion  has  been  made  of  adding  to  it  a  twen- 
tieth part  of  cream  j1  and  Sir  Henry  Marsh  tells  us,  that  the  laxative 
property  which  asses'  milk  possesses,  and  which  sometimes  interferes 
with  our  employing  it,  is  effectually  destroyed  by  heating  it  to  212°. 
If,  as  sometimes  will  happen,  even  when  this  best  substitute  for  the 
mother's  milk  is  given,  the  infant's  bowels  should  still  be  relaxed,  the 
addition  of  about  a  fourth  part  of  lime  water  will  generally  control  this 
diarrhoea. 

When  cowsr  milk  is  given,  it  must  be  borne  in  mind  that  it  contains 
more  casein  than  human  milk,  and  less  sugar ;  and  that  it  is  therefore 
necessary  that  it  should  be  given  in  a  diluted  state,  and  slightly 
sweetened.  The  degree  of  dilution  must  vary  according  to  the  infant's 
age :  at  first,  ^the  milk  may  be  mixed  with  an  equal  quantity  of  water, 
but  as  the  child  grows  older,  the  proportion  of  water  may  be  reduced 
to  one-third.  Attention  must  be  paid  to  the  temperature  of  the  food 
when  given  to  the  infant,  which  ought  to  be  as  nearly  as  possible  the 
same  as  that  of  the  mother's  milk,  namely,  from  90°  to  95°  Fahrenheit; 
and  in  all  cases  in  which  care  is  needed,  a  thermometer  should  be  em- 
ployed, in  order  to  ensure  the  food  being  always  given  at  the  same 
temperature.  Human  milk  is  alkaline ;  and  even  if  kept  for  a  consi- 
derable time,  it  shows  but  little  tendency  to  become  sour.  The  milk  of 
animals  in  perfect  health  likewise  invariably  presents  an  alkaline  reac- 
tion, and  that  of  cows  when  at  grass  forms  no  exception  to  this  rule. 
Comparatively  slight  causes,  however,  exert  a  marked  influence  upon 
the  milk  of  the  cow  in  this  respect ;  and  if  the  animal  be  shut  up  and 
stall-fed,  its  milk  almost  constantly  assumes  a  strongly  acid  property2 
— a  fact  which  of  itself  is  sufficient  to  account  for  the  symptoms  of 
gastric  and  intestinal  disorder  so  often  produced  by  it  in  the  case  of 
children  brought  up  in  large  towns.  Whenever,  therefore,  the  attempt 
is  made  to  rear  an  infant  by  hand,  under  circumstances  which  render 
it  impossible  to  obtain  the  milk  of  cows  which  are  at  pasture,  it  is 
desirable  that  the  milk  should  be  daily  tested,  and  that  any  acidity 

1  By  Mr.  Moore,  of  Dublin,  in  his  paper  already  referred  to. 

2  See  the  results  of  Dr.  Mayer's  observations  on  cows  in  Berlin  and  its  neighbourhood, 
in  a  valuable  paper  on  the  Artificial  Feeding  of  Infants,  in  the  first  volume  of  the  Ver- 
handlungen  der  Gesellschaft  fur  Geburtshulfe  in  Berlin,  8vo.  p.  56,  Berlin,  1846 ;  and 
also  two  papers  by  Dr.  Peddie  in  the  London  a  nd  Edinburgh  Monthly  Journal  for  1848. 


334  CHARACTERISTICS   OF   UNHEALTHY  MILK. 

should  be  neutralized  by  the  addition  of  lime  water,  or  of  prepared 
chalk,  in  quantity  just  sufficient  to  impart  to  it  a  slightly  alkaline  reac- 
tion. If  the  bowels  be  disposed  to  be  constipated,  carbonate  of  mag- 
nesia may  be  substituted  for  the  chalk.  Unfortunately,  there  seem,  as 
I  stated  a  day  or  two  ago,  to  be  good  reasons  for  believing  that  the 
milk  of  stall-fed  cows  often  undergoes  a  deterioration  much  more  serious 
than  the  merely  becoming  ascescent ;  and  that  changes  not  infrequently 
take  place  in  it  such  as  must  render  it  wholly  unfit  for  an  infant's  food, 
and  calculated  only  to  promote  disease.  The  possibility  of  their  occur- 
rence shews  the  necessity,  when  an  infant  who  is  brought  up  by  hand 
fails  in  health,  for  making  a  careful  inquiry  into  the  source  of  the  milk 
with  which  it  is  fed;  and  for  examining  the  fluid,  both  chemically  and 
under  the  microscope,  before  proceeding  to  prescribe  remedies  for 
ailments  which  may  be  caused  entirely  by  the  unwholesome  nature  of 
its  food. 

It  can  scarcely  be  necessary  to  add,  that  such  examination  of  the 
milk  as  is  necessary  for  practical  purposes  is  extremely  simple ;  since 
unhealthy  milk  is  characterized  not  only  by  the  weakening  or  complete 
loss  of  its  alkaline  reaction,  but  also  by  the  agglutination  of  the  oil 
globules,  which  in  health  float  about  perfectly  free  in  the  colourless 
serum,  by  the  presence  of  numerous  large  granular  bodies  similar  to 
those  which  have  been  termed  colostrum  corpuscules,  and  even  in  some 
instances  of  epithelium  scales  from  the  lactiferous  tubes.  Similar 
changes,  too,  take  place  in  the  human  milk ;  and  the  use  of  the  micro- 
scope will  therefore  often  help  you  to  solve  the  question  of  whether  a 
woman  should  wean  her  infant,  or  whether  she  may  safely  continue  to 
suckle  it  longer. 

It  may  suffice,  for  to-day,  thus  to  have  brought  before  you  the  main 
principles  by  which  you  must  be  guided  in  the  attempt  to  rear  a  young 
infant  by  hand.  Details  as  to  the  general  dietetic  management  of 
infancy  or  childhood  would  not  only  carry  us  beyond  the  period  allotted 
for  this  lecture,  but  would  be  a  departure  from  our  special  object  of 
investigating  the  diseases  of  early  life. 


LECTURE    XXVIII. 

Atrophy  of  Young  Children — not  a  special  disease,  but  a  condition  that  may  be  induced 
by  various  causes. 

Thrush,  a  peculiar  affection  of  the  mouth  often  associated  with  impaired  nutrition — 
its  different  names  of  aphthae  and  inuguet  apply  to  different  degrees  of  same  affection 
— conflicting  opinions  as  to  nature  of  the  deposit — treatment. 

Dentition — high  rate  of  mortality  while  it  is  going  on — erroneous  views  "with  reference 
to  the  cause  of  this,  and  to  the  nature  of  the  process — physiology  of  dentition — order 
of  appearance  of  the  teeth — pauses  in  their  evolution  frequently  attended  with  local 
suffering — various  morbid  conditions  of  mucous  membrane  of  the  mouth  excited  by  it. 

Management  of  children  when  teething — circumstances  under  which  lancing  the  gums  is 
likely  to  be  useful — dietetic  and  medical  management — treatment  of  affections  of  the 
mouth — caution  with  reference  to  cure  of  cutaneous  eruptions  during  the  time  of 
teething. 

At   our  last  meeting  we  were  occupied  with  various  preliminary 
inquiries,  of  importance  to  the  thorough  understanding  of  the  diseases 


ATROPHY    OF    YOUNG   CHILDREN.  335 

of  the  digestive  organs  in  early  life,  on  the  study  of  which  we  now 
are  about  to  enter.  We  examined  the  structural  and  functional  pecu- 
liarities of  those  organs  in  the  young,  and  endeavoured  to  ascertain 
wherein  consists  the  special  fitness  of  the  mother's  milk  for  the 
nutriment  of  her  infant.  We  further  tried  to  discover  the  mode  in 
which  other  food  acts  injuriously  on  the  infant,  and  sought  from  the 
knowledge  thus  acquired  to  deduce  rules  for  our  guidance,  whenever  it 
should  become  necessary  to  provide  a  young  child  with  a  substitute 
for  that  sustenance  which  nature  intended  that  it  should  receive. 

These  considerations  naturally  brought  under  our  notice  the  symp- 
toms which  betoken  that  the  process  of  nutrition  is  imperfectly  carried 
on,  and  the  appearances  which,  when  death  takes  place  from  this 
cause,  are  revealed  on  an  examination  of  the  body.  It  may  seem  to 
you,  however,  that  the  atrophy  of  young  children  calls  for  a  more 
elaborate  study  than  ours  of  yesterday,  and  for  a  minute  account  of  its 
symptoms.  But  to  attempt  this  would  be  to  enter  upon  almost  endless 
details,  whi6h  would  leave  upon  your  memory  no  clear'  impression. 
Whether  all  food  is  withheld  from  an  infant,  or  whether  it  is  suppled 
with  food  which  it  cannot  assimilate,  or  whether  disease  prevent  it  from 
digesting  food  on  which  a  healthy  infant  would  thrive,  the  main  result 
is  the  same,  and  the  child  dies  of  inanition.  Various  accidents  may 
abridge  the  infant's  life,  or  make  it  sink,  in  one  case,  under  circum- 
stances somewhat  different  from  those  which  precede  its  death  in 
another.  Sometimes  the  vital  powers  grow  so  feeble,  that  the  inspi- 
ratory efforts  no  longer  suffice  to  fill  the  lungs  with  air  ;  sometimes  the 
irritable  stomach  rejects  all  food,  while  at  other  times  diarrhoea  comes  on 
which  no  medicine  can  check.  But  in  these  symptoms  there  is  nothing 
characteristic  of  one  special  cause, — they  may  occur  alike  in  the 
infant  who,  though  healthy  when  born,  was  early  deprived  of  its 
mother's  milk,  or  in  the  child  who  is  the  subject  of  general  tuberculous 
disease,  or  whose  strength  has  been  exhausted  and  its  digestive  powers 
impaired  by  dysentery.  The  symptoms,  then,  that  accompany  the 
atrophy  of  new-born  children,  must  be  expected  to  vary  much  in 
different  cases  ;  while  the  considerations  brought  before  you  in  the  last 
lecture  will,  I  think,  furnish  you  with  a  clue  to  the  complete  under- 
standing of  them  all. 

Before  we  pass,  however,  to  the  special  study  of  the  diseases  of  the 
digestive  organs  and  its  appendages,  I  would  beg  to  call  your  attention 
to  that  peculiar  condition  of  the  mucous  memhrane  of  the  mouth  popu- 
larly known  as  the  thrush,  which  is  so  frequently  met  with  in  connection 
with  the  artificial  feeding  of  young  infants, — so  almost  invariably  asso- 
ciated with  the  evidences  of  their  impaired  nutrition,  that  the  present 
seems  to  be  the  best  time  for  noticing  it. 

If  you  examine  the  mouth  of  a  young  infant  on  whom  the  attempt  is 
being  made  to  bring  it  up  without  the  mother's  milk,  you  will  often 
observe  its  mucous  membrane  to  be  beset  with  numerous  small  white 
spots,  which  look  like  little  bits  of  curd  lying  upon  its  surface,  but 
which  on  a  more  attentive  examination  are  found  to  be  so  firmly  adhe- 
rent to  it  as  not  to  be  removed  without  some  difficulty,  when  the 
subjacent  membrane  is  left  of  a  deep  red  colour,  and  often  bleeding 


336  INFANTILE   ATROPHY   NOT   A    SPECIAL   DISEASE. 

slightly.  These  specks  appear  upon  the  inner  surface  of  the  lips,  espe- 
cially near  the  angles  of  the  mouth  or  the  inside  of  the  cheeks ;  and 
upon  the  tongue,  where  they  are  more  numerous  at  the  tip  and  edges 
than  towards  the  centre.  They  are  likewise  seen  upon  the  gums, 
though  less  frequently,  and  in  smaller  number.  When  they  first  appear, 
they  are  in  general  of  a  circular  form,  scarcely  larger  than  a  small 
pin's  head ;  but  after  these  aphthce,  as  they  are  called,  have  existed  for 
a  day  or  two,  some  of  the  spots  became  three  or  four  times  as  large, 
while  at  the  same  time  they  in  general  lose  something  of  their  circular 
form.  By  degrees  these  small  white  crusts  fall  off  of  their  own  accord, 
usually  leaving  the  mucous  membrane  where  they  were  seated  redder 
than  before — a  colour  which  gradually  subsides  as  the  mouth  returns 
to  its  natural  condition ;  or  the  white  specks  are  reproduced,  and  again 
detached,  several  times  before  the  membrane  resumes  its  healthy  aspect. 
In 'some  cases  these  specks  coalesce,  or  the  deposit,  from  its  first 
appearance,  presents  more  of  the  character  of  a  false  membrane  ;  and 
the  mouth  is  then  seen  to  be  extensively  coated  with  it.  Under  these 
circumstances,  the  deposit  generally  loses  something  of  the  dead  white 
colour  characteristic  of  the  smaller  spots,  and  presents  a  slightly  yel- 
lowish tint.  On  the  continent,  where  the  severer  form  of  the  affection 
is  not  infrequently  seen,  it  was  supposed,  though  the  opinion  is  now 
generally  abandoned,  to  be  an  essentially  different  ailment  from  the 
slighter  "forms  of  the  disease,  in  which  the  points  of  deposit  are  distinct. 
Accordingly,  the  term  aphthoe  has  been  restricted  by  many  French 
writers  to  the  milder  variety,  while  they  have  applied  the  name  cf 
muguet  to  designate  its  severer  form.  I  use  the  English  word  thrush1 
to  denote  both  forms,  regarding  them  merely  as  degrees  of  the  same 
malady. 

Children  in  whom  either  form  of  this  deposit  exists  in  any  consider- 
able degree,  usually  appear  out  of  health  ;  and  it  will  generally  be 
found  on  inquiry  that  this  indisposition  had  preceded  for  some  days  the 
eruption  in  the  mouth.  For  the  most  part  such  children  are  emaciated, 
and  present  those  symptoms  that  attend  upon  imperfect  nutrition, 
while  the  bowels  are  in  general  relaxed,  and  the  evacuations  of  a  green 
colour,  and  very  sour.  The  acridity  of  the  motions  sometimes  irritates 
and  inflames  the  margins  of  the  anus,  and  a  blush  of  erythematous 
redness  not  infrequently  extends  over  the  nates  and  buttocks,  while  in 
some  instances  a  deposit  of  a  similar  kind  to  that  in  the  mouth  occupies 
the  edges  of  the  intestine.  The  deposit  in  the  mouth  sometimes  ren- 
ders sucking  very  difficult,  and  may  even  impair  deglutition,  while  the 
child,  thus  obtaining  but  little  food,  lies  in  a  state  of  torpor  and  drow- 
siness, the  result  of  its  debility. 

In  its  more  serious  form  this  affection  was  said  to  prove  fatal  to  a 
large  number  of  the  inmates  of  the  different  foundling  hospitals  on  the 
continent.  Observation  has  shown,  however,  that  although  the  deposit 
exists  in  the  mouth  of  very  many  children  who  die  in  those  institutions, 
yet  their  death  is  due  not  to  the  local  affection,  but  to  the  constitutional 
disease,  of  which  that  is  only  one  out  of  many  evidences. 

1  A  word  the  etymology  of  which  is  uncertain  ;  as  is  that  of  its  Swedish  synonym 
Torsk,  and  the  Danish  and  Norwegian  Trodske. 


INTIMATE   NATURE   OF   THE   DEPOSIT.  337 

At  the  time  when  the  local  affection  was  regarded  as  in  itself  of  such 
grave  import,  every  inquiry  into  its  nature  presented  a  degree  of  prac- 
tical importance  which  no  longer  attaches  to  it.  The  differences  between 
that  slight  ailment,  in  which  the  deposit  appears  in  the  form  of  a 
number  of  isolated  specks,  and  the  more  serious  affection,  in  which  it 
completely  lines  the  mouth,  were  thought  to  be  differences  of  kind,  not 
merely  of  degree.  This  opinion  is  now,  however,  ascertained  to  be 
erroneous  ;  and  though  observers  are  not  yet  quite  agreed  as  to  the 
intimate  nature  of  the  deposit,  yet  its  identity  in  both  cases  is  no 
longer  matter  of  dispute.  The  microscope  has  not  yet  cleared  up  all 
doubts  with  reference  to  its  nature ;  and  while  some  persons  are  dis- 
posed to  regard  the  deposit  as  being  a  parasitic  growth,  like  the  mus- 
cardine  which  attacks  the  silk-worm,  or  the  confervse  found  on  other 
living  animals,  other  observers  look  upon  it  as  a  false  membrane  similar 
to  that  of  diphtheritis  or  croup,  and  consider  that  the  development-  of 
confervae  in  its  substance  is  an  accidental  occurrence,  and  one  which  is 
frequently  absent.1  According  to  the  former  opinion,  the  white  deposit 
is  made  up  of  epithelium  thickened  by  swelling  of  its  cells,  in  the  midst 
of  which  a  parasitic  growth  is  developed  in  greater  or  less  abundance, 
so  that  the  aphthous  mass  is  composed  partly  of  it,  partly  of  epithelial 
cells.  The  relation  of  the  two  elements  to  each  other  varies  according 
to  the  duration  of  the  disease  and  the  age  and  constitution  of  the 
patient ;  but  the  development  of  the  aphthophytes,  as  this  growth  has 
been  termed,  is  regarded  as  essential  to  the  production  of  the  affection. 

On  the  other  hand,  the  existence  of  the  vegetable  parasite  has  been 
considered  to  be  purely  accidental,  the  disease  consisting  according  to 
this  view  oi\  its  nature,  essentially  in  the  formation  of  a  false 
membrane  beneath  the  epithelium  ;  this  adventitious  production  serving 
as  a  nidus  for  the  parasitic  growth  which,  under  favourable  circum- 
stances, may  be  developed  in  it.  The  fibrils  observed  in  the  deposit, 
which  by  some  persons  have  been  regarded  as  proving  it  to  be  in 
reality  a  vegetable  parasite,  are  stated  by  the  opponents  of  that  view 
to  be  nothing  more  than  very  delicate  fibres,  having  a  parallel 
arrangement,  and  owing  the  branched  appearance  which  they 
sometimes  seem  to  present  entirely  to  an  optical  illusion. 

I  cannot  pretend  to  decide  from  personal  observation,  the  point  at 
issue  between  the  supporters  of  these  two  conflicting  theories  ;  but  my 
opinion  decidedly  leans  to  the  adoption,  as  generally  correct,  of  that 
view  which  sees  in  the  deposit  the  result  of  an  inflammatory  process 
ending  in  the  formation  of  false  membrane,  wherein  a  parasitic  growth 
may  become  developed.  The  endemic  prevalence  of  thrush  in 
foundling  hospitals,  and  other  similar  institutions,  may  be  accounted 

1  Not  to  encumber  this  lecture  with  the  citation  of  authorities,  it  may  suffice  to  refer 
to  the  valuable  essay  of  Dr.  Berg,  of  Stockholm,  analyzed  in  the  Journal  fur  Kinderkrank- 
heiten  for  September  and  October,  1847,  and  since  translated  into  German,  as  a  most 
able  defence  of  the  first-mentioned  opinion  ;  and  to  the  papers  by  Dr.  Kronenberg,  of 
Moscow,  in  that  Journal  for  February  and  September  of  the  same  year,  for  observa- 
tions and  arguments  tending  to  support  the  opposite  view.  With  reference  to  the  pro- 
duction of  confervee  on  the  mucous  surfaces  of  the  human  body  in  disease,  the  fullest 
account  is  given  by  Hannover,  in  Miiller's  Archiv  for  1842,  p.  281. 

22 


I 

338         TREATMENT  OF  THE  AFFECTIONS  OF  THE  MOUTH. 

for  by  the  noxious  influences  to  which  infants  are  there  subjected ; 
and  which,  as  we  have  already  seen,  in  the  case  of  diphtheritis  and  of 
malignant  coryza,  are  favourable  to  the  formation  of  false  membranes 
upon  the  different  mucous  surfaces.  The  frequency  of  the  parasitic 
growth  in  the  false  membrane  is  possibly  dependent  on  the  actual 
transplantation  of  its  sporules  from  one  patient  to  another  by  means 
of  the  cups,  spoons,  &c.  used  by  them  in  common,  and  generally 
without  sufficient  attention  being  paid  to  ensure  their  perfect 
cleanliness.  Such  at  least,  is  the  conclusion  to  which  Dr.  Berg, 
of  Stockholm,1  was  led  by  his  observation,  while  his  experiments  seem 
further  to  prove  the  possibility  of  exciting  the  disease  by  the  deposit 
of  these  sporules  upon  the  surface  of  the  healthy  mucous  membrane, 
which,  in  all  the  four  instances  where  it  was  tried,  was  followed  by 
the  developement  of  the  confervae  and  the  alteration  of  the  epithelium 
of  the  mouth. 

In  the  treatment  of  this  affection,  the  removal  of  the  constitutional 
disturbance  is  of  at  least  as  much  importance  as  the  ministering  to 
the  local  malady.  It  is,  however,  only  the  local  treatment  that  it 
will  be  expedient  to  dwell  on  here,  since  the  general  management  of 
the  case  must  vary  as  widely  as  the  causes  to  which  the  affection  of 
the  mouth  is  due.  One  point  of  considerable  moment,  and  to  which 
less  care  than  it  deserves  is  usually  paid,  is  the  removing  from 
the  mouth,  after  each  time  that  the  infant  is  fed,  all  remains  of  the 
milk,  or  other  food  that  it  has  taken.  For  this  purpose,  whenever  the 
least  sign  of  thrush  appears  in  the  infant,  the  mouth  should  be  carefully 
wiped  out  with  a  piece  of  soft  rag,  dipped  in  a  little  warm  water,  every 
time  after  food  has  been  given.  Supposing  the  attack  to  be  but  slight, 
this  precaution  will  of  itself  suffice  in  many  instances  to  remove  all 
traces  of  the  affection  in  two  or  three  days.  If,  however,  there  be 
much  redness  of  the  mucous  membrane  of  the  mouth,  or  if  the  aphthous 
spots  be  numerous,  some  medicated  topical  application  is  useful. — 
Various  detergents  have  been  recommended,  among  which  the  mel 
boracis,  and  a  mixture  of  the  Armenian  bole  with  honey,  are  very 
frequently  employed.  An  objection,  however,  has  been  raised,  and 
I  think  on  good  grounds,  to  any  application  into  the  composition 
of  which  honey  or  other  saccharine  matters  enter,  on  the  ground  that 
the  tendency  of  those  substances  to  pass  into  a  state  of  fermentation 
will  make  them  favour  rather  than  prevent  the  formation  of  conferva? 
in  the  interior  of  the  mouth.  It  is  my  custom  to  dissolve  a  scruple  or 
half  a  drachm  of  borax  in  an  ounce  of  water,  and  to  direct  that  after 
the  mouth  has  been  carefully  cleansed  with  warm  water,  this  lotion 
should  be  applied  to  it  on  a  piece  of  lint  or  soft  linen.  In  the  milder 
forms  of  the  affection,  the  borax  lotion  usually  answers  every  purpose. 
Should  it,  however,  appear  insufficient,  a  solution  of  five  grains  of  the 
nitrate  of  silver  in  an  ounce  of  distilled  water  may  be  employed  in 
the  same  way  twice  a  day,  while  at  other  times  the  solution  of  borax 
may  be  used  in  the  manner  just  directed. 

The  close  connection  that  subsists  between  this  local  affection  and 

p 
i  Ueber  die  Schwiimmchen  der  Kinder,  8vo.  Bremen,  1 848,  pp.  76-80. 


MORTALITY   DURING   DENTITION.  339 

-the  condition  of  generally  impaired  nutrition,  which  engaged  our  atten- 
tion yesterday,  induced  me  to  br^ng  the  subject  now  under  your  notice. 
I  do  not  know,  however,  that  any  better  plan  can  be  adopted,  in 
studying  the  diseases  of  the  organs  of  digestion  and  assimilation,  than 
closely  to  follow  an  anatomical  arrangement,  and  to  consider,  first,  the 
diseases  of  the  mouth,  then  those  of  the  stomach,  then  those  of  the 
intestines,  and  lastly  those  of  the  other  abdominal  viscera. 

It  may,  perchance,  seem  to  you  that,  according  to  this  plan,  it  is  not 
proposed  to  assign  any  place  of  importance  to  the  disorders  of  dentition, 
though  in  our  tables  of  mortality  we  find  teething  registered  as  having 
occasioned  the  death  of  nearly  5  (4.8)  percent,  of  all  children  who  died 
in  this  metropolis  under  one  year  old,  and  of  7.3  per  cent,  of  those  who 
died  between  the  age  of  twelve  months  and  three  years.  Many  other 
circumstances,  too,  tend  to  increase  the  impression  which  this  fact  natu- 
rally makes ;  for  not  only  do  nurses  attribute  to  teething  the  most 
varied  forms  of  constitutional  disturbance,  and  mothers  express  serious 
apprehensions  as  the  period  of  dentition  approaches,  but  medical  men 
hold  forth  to  anxious  parents  the  expectation  that  their  child  will  have 
better  health  when  it  has  cut  all  its  teeth.  The  time  of  teething,  too, 
is  in  reality  one  of  more  than  ordinary  peril  to  the  child ;  though  why 
it  should  be  so  is  not  always  rightly,  understood.  It  is  a  time  of  most 
active  development  of  the  organism — a  time  of  transition  from  one 
mode  of  being  to  another,  in  respect  of  all  those  important  functions 
by  whose  due  performance  the  body  is  nourished  and  built  up.  Sta- 
tistics,1 embracing  the  largest  numbers,  prove  the  dangers  of  this 
period,  and  warrant  us  in  regarding  the  completion  of  the  process  of 
teething  as  a  Xair  subject  for  congratulation. 

The  error  which  has  been  committed  with  reference  to  this  matter, 
not  merely  by  the  vulgar  but  by  members  of  our  own  profession  also, 
consists,  not  in  overrating  the  hazards  of  the  time  when  changes4 so 
important  are  being  accomplished,  but  in  regarding  only  one  of  the 
manifestations — though  that,  indeed,  is  the  most  striking  one — of  the 
many  important  ends  which  nature  is  then  labouring  to  bring  about. 
A  child  in  perfect  health  usually  cuts  its  teeth  at  a  certain  time  and  in 
a  certain  order,  just  as  a  girl  at  a  certain  age  presents  the  various 
signs  of  approaching  puberty,  and  at  length  begins  to  menstruate.  In 
her  case  we  do  not  fix  our  attention  solely  on  the  menstrual  flux  ;  nor, 
if  it  fail  to  appear,  do  we  have  recourse  to  the  empirical  employment 
of  emmenagogue  medicines.  We  examine  into  the  cause  of  its  absence  ; 
try  to  ascertain  whether  it  depends  on  the  state  of  the  health  in 
general,  or  of  the  uterine  system  in  particular,  and  regulate  accord- 
ingly our  attempts  at  cure.  The  epoch  of  dentition  is  to  be  looked  at 
just  in  the  same  way  as  that  in  which  we  regard  the  epoch  of  puberty. 
Constitutional  disturbance  is  more  common,  and  serious  disease  more 
frequent,  at  these  times  than  at  others;  but  their  causes  lie  deeper  than 
the  tooth  which  irritates  the  gum  that  it  has  not  yet  pierced  in  the  one 
case,  or  than  the  womb  which  has  not  yielded  the  due  discharge  of 

l  See,  for  instance,  the  table  of  mortality  at  different  months,  at  p.  36  of  MM.  Quetelet 
et  Smits,  Recherches  surla  Reproduction  et  la  Mortality,  &c.  8vo.     Bruxelles,  1842. 


340  ORDER  IN  WHICH  THE  TEETH  APPEAR. 

blood  in  the  other.  .You  might  produce  haemorrhage  from  the  uterine* 
vessels  in  the  latter  instance,  or  might  cut  through  the  gum  which 
enclosed  the  teeth  in  the  former,  with  no  other  effect  than  that  of 
aggravating  the  condition  of  your  patient. 

In  speaking  of  the  diseases  of  the  nervous  and  respiratory  systems, 
your  attention  has  on  several  occasions  been  drawn  to  the  greater 
frequency  of  some  of  those  affections  just  at  the  time  when  the  process 
of  teething  is  going  on ;  and  you  will  have  to  remark  a  similar  fact 
with  reference  to  some  of  the  disorders  of  the  abdominal  viscera. 
These  maladies,  however,  are  not  peculiar  to  the  time  of  teething,  nor, 
when  they  occur  at  that  period,  do  they  present  symptoms  different 
from  those  which  characterise  them  under  other  circumstances,  while 
it  often  happens  that  the  changes  which  mark  the  transition  from 
infancy  to  childhood  are  accomplished  so  quietly  as  to  be  attended  with 
no  notable  disturbance  of  the  general  health. 

The  great  changes  which  nature  is  constantly  bringing  about  around 
us  and  within  us,  are  the  result  of  laws  operating  silently  but  unceas- 
ingly ;  and  hence  it  is  that  in  her  works  we  see  little  of  the  failure 
which  often  disappoints  human  endeavours,  or  of  the  dangers  which 
often  attend  on  their  accomplishment.  Thus,  when  nature's  object  is  to 
render  the  child  no  longer  dependent  on  the  mother  for  its  food,  she 
begins  to  prepare  for  this  long  beforehand.  The  first  indication  of  it 
is^furnished  by  the  greatly  increased  activity  of  the  salivary  glands. 
If  you  look  into  the  mouth  of  a  young  infant,  you  will  be  struck  by  the 
very  small  amount  of  saliva  that  moistens  its  surface — a  circumstance 
which  explains  in  great  measure  the  tendency  to  dryness  which  the 
tongue  then  presents  under  the  influence  of  very  trivial  ailments. 
About  the  fourth  or  fifth  month,  however,  this  condition  undergoes  a 
marked  alteration :  the  mouth  is  now  found  constantly  full  of  saliva,  and 
the  child  is  continually  drivelling ;  but  no  other  indication  appears  of  the 
approach  of  the  teeth  to  the  surface,  except  that  the  ridge  of  the  gums 
sometimes  becomes  broader  than  it  was  before.  No  further  change 
may  take  place  for  many  weeks  :  and  it  is  generally  near  the  end  of 
the  seventh  month,  oftener  later  than  earlier,  before  the  first  teeth 
make  their  appearance.  The  middle  incisors  of  the  lower  jaw  are 
generally  the  first  to  pierce  the  gum  ;  next  in  order  appear  the  middle 
incisors  of  the  upper  jaw,  then  the  lateral  incisors  of  the  upper  jaw, 
and  next  the  lateral  incisors  of  the  lower.  The  first  four  molars  next 
succeed,  and  often  without  any  very  definite  order  as  to  whether  those  of 
the  upper  or  of  the  lower  jaw  are  first  visible,  though,  in  the  majority 
of  cases,  the  lower  molars  are  the  first  to  appear.  The  four  canine 
teeth  succeed ;  and,  lastly,  the  four  posterior  molars — making,  in  all, 
the  number  of  twenty  deciduous  teeth. 

We  must  not,  however,  picture  to  ourselves  this  process  as  going  on 
uninterruptedly  until  completed — a  mistake  into  which  parents  often 
fall,  whose  anxiety  respecting  their  children  is  consequently  excited  by 
observing,  that,  after  several  teeth  have  appeared  in  rapid  succession, 
dentition  appears  to  come  to  a  standstill.  Nature  has  so  ordered  it, 
that  the  process  of  dentition,  beginning  at  the  seventh  or  eighth  month, 
shall  not  be  completed  until  the  twenty-fourth  or  thirtieth ;  and  has 


AFFECTIONS   OF   THE  MOUTH   DURING  TEETHING.  841 

doubtless  done  so  in  some  measure  with  the  view  of  diminishing  the  risk 
of  constitutional  disturbance  which  might  be  incurred  if  the  evolution 
of  the  teeth  went  on  without  a  pause.  A  little  observation  will  show 
you,  that,  while  the  irruption  of  the  lower  central  incisors  is  generally 
completed  in  a  week,  an  interval  of  six  weeks  or  two  months  often  takes 
place  before  the  upper  incisors  make  their  appearance,  which  then  are 
Quickly  followed  by  the  lower  lateral  incisors.  A  pause  of  three  or 
four  months  now  frequently  occurs  before  we  see  the  first  molar  teeth, 
another  of  equal  length  previous  to  the  appearance  of  the  canine  teeth, 
and  then  another  still  longer  before  the  last  molars  are  cut. 

Though  a  perfectly  natural  process,  dentition  is  yet  almost  always 
attended  with  some  degree  of  suffering.  Many  of  us,  no  doubt,  can 
remember  feeling  much  pain  when  we  cut  our  wisdom  teeth,  and  chil- 
dren probably  experience  the  same  kind  of  annoyance.  This,  however, 
is  not  always  the  case ;  for  sometimes  we  discover  that  an  infant  has 
cut  a  tooth,  who  had  yet  no  sign  of  discomfort,  nor  any  indication  that 
dentition  was  commencing,  with  the  exception  of  an  increased  flow  of 
saliva.  More  frequently,  indeed,  the  mouth  becomes  hot,  and  the  gums 
look  tumid,  tense,  and  shining,  while  the  exact  position  of  each  tooth  is 
marked,  for  some  time  before  its  appearance,  by  the  prominence  of  the 
gum :  or  the  irruption  of  the  teeth  is  preceded  or  accompanied  by  a 
somewhat  different  condition  of  the  mouth,  in  which  there  are  much 
heat,  and  intense  redness  of  the  mucous  membrane,  an  extremely 
copious  flow  of  thin  saliva,  and  a  disposition  to  the  formation  of  small 
aphthous  ulcerations  on  the  tongue,  at  the  outer  surface  of  the  alveolae, 
or  at  the  duplicature  of  the  lip,  though  the  gums  themselves  may  not 
be  particularly  swollen  or  painful.  Either  of  these  states  is  usually 
attended  with  some  degree  of  febrile  disturbance,  and  apparently  with 
considerable  suffering  to  the  infant,  who  is  constantly  fretful  and  pee- 
vish, or  cries  out  occasionally  as  if  in  pain.  A  third  morbid  condition 
of  the  mouth  is  sometimes  seen,  which  is  usually  ushered  in  or  attended 
by  very  considerable  fever  and  disorder  of  the  chylopoietic  viscera. 
The  gums  then  become  extremely  hot  and  swollen,  and  usually  tender, 
especially  over  some  tooth  or  other  in  particular,  and  in  that  situation 
we  find  the  gum  swollen  up  into  a  kind  of  little  tumor.  Small  unhealthy 
ulcerations,  with  a  sloughy  appearance,  often  form  upon  the  summit  of 
the  gum,  and  especially  around  any  tooth  which  has  partly  pierced 
through  it.  To  this  affection,  which  is  often  very  painful,  and  often 
difficult  of  cure,  the  name  of  Odontitis  Infantum  has  been  applied  by 
some  continental  writers. 

In  considering  the  rules  by  which  you  must  direct  the  management 
of  children  ichen  teething,  it  can  scarcely  be  necessary  to  caution  you 
against  regarding  all  diseases  that  may  come  on  during  dentition  as  of 
necessity  connected  with  that  process,  or  with  the  general  changes  then 
going  on  in  the  organism  :  still  less  need'I  warn  you  against  looking 
upon  all  ailments  at  that  time  as  symptomatic  of  the  local  uneasiness 
which  the  child  suffers  in  its  mouth.  Some  persons,  indeed,  act  as  if 
they  held  both  these  notions  in  their  fullest  extent ;  and,  following  up 
in  practice  this  coarsely  mechanical  theory,  they  lance  the  gums  of 
every  child  who  has  not  yet  cut  all  its  teeth,  almost  or  altogether  irre- 


342  RULES  FOR  THE  USE  OF  THE  GUM-LANCET. 

spective  of  the  nature  of  the  affection  from  which  it  suffers.  Such  a 
proceeding  is  nothing  better  than  a  piece  of  barbarous  empiricism, 
which  causes  the  infant  much  pain,  and  is  useless  or  mischievous  in  a 
dozen  instances,  for  one  in  which  it  affords  relief.  Still  less  is  the  gum- 
lancet  to  be  applied,  merely  with  the  view  of  expediting  the  process 
that  nature  is  engaged  in.  The  gradual  protrusion  of  the  teeth  occa- 
sions the  slow  absorption  of  the  superjacent  gum,  and  for  this  process 
the  division  of  the  gum  by  a  scalpel  forms  at  best  but  a  clumsy  sub- 
stitute. 

The  circumstances  under  which  the  use  of  the  gum-lancet  is  really 
indicated  are  comparatively  few.  You  may  employ  it  when  a  tooth  is 
so  nearly  through  that  you  can  feel  sure  it  will  burst  the  gum  in  a  day 
or  two  at  latest ,  for  then,  by  making  an  incision  through  the  very  thin 
gum,  you  may  certainly  spare  the  infant  some  suffering.  Or,  you  may 
lance  the  gums  if  they  be  red,  and  swollen,  and  tense,  and  injected ;  but 
then  you  scarify  them  in  order  that  they  may  bleed,  and  that  their 
congested  vessels  may  be  thus  relieved :  you  do  not  divide  them  to  let 
out  the  imprisoned  tooth.  Under  such  circumstances  it  may  be  neces- 
sary to  repeat  your  scarification  several  times  with  the  same  object  ; 
and  it  is  therefore  well  to  explain  beforehand  to  the  mother  the  reasons 
of  your  proceeding,  lest  she  should  expect  to  see  the  tooth  at  once  make 
its  appearance.  There  are,  besides,  cases  in  which  the  general  consti- 
tutional disturbance  that  often  attends  dentition  continues  for  several 
days,  or  even  weeks,  while  yet  the  condition  of  the  swollen  gum  remains 
unaltered,  and  the  tooth  does  not  seem  to  approach  nearer  to  the  surface. 
In  such  a  case  you  may  try  the  experiment  of  lancing  the  gums,  or  you 
may  try  it  in  the  case  of  a  child  in  whom  you  have  already  observed  that 
catarrh,  or  fever,  or  diarrhoea,  has  been  excited  by  the  approach  of  each 
tooth  to  the  surface,  and  has  ceased  immediately  that  the  tooth  has 
pierced  the  gum.  Lastly,  in  the  cases  of  sudden,  and  apparently  cause- 
less convulsions,  which  are  occasionally  met  with  in  children,  you  will  be 
justified  in  lancing  the  gums  if  you  find  that  the  process  of  dentition  is 
going  on  with  activity ;  but  you  would  do  no  good  if  you  lanced  the 
gums  during  one  of  those  periods  of  repose  which  you  will  remember 
interrupt  from  time  to  time  the  evolution  of  the  teeth.  You  must 
therefore  inquire  not  merely  what  teeth  the  child  has  cut,  but  also  when 
the  last  made  their  appearance  ;  and  must  seek  for  some  evidence  either 
that  the  process  is  still  going  on,  or  that  its  activity  is  once  more 
recommencing,  before  you  would  have  ground  for  supposing  the  source 
of  irritation  of  the  nervous  system  to  be  such  as  your  gum-lancet  would 
relieve. 

If  the  process  of  teething  be  going  on  perfectly  naturally,  no 
interference,  medical  or  other,  is  either  necessary  or  proper.  The 
special  liability  of  children  to  illness  at  that  time  must  indeed  be  borne 
in  mind,  and  care  must  betaken  not  to  make  any  alteration  in  the 
infant's  food  while  it  is  actually  cutting  its  teeth,  but  rather  to  choose 
the  opportunity  of  some  one  of  those  pauses  to  which  reference  has 
been  made,  as  occurring  between  the  dates  of  irruption  of  the  successive 
teeth,  for  any  such  change.  Should  the  child  at  any  time  appear  very 
feverish,  some  simple  febrifuge  medicine  may  be  given  ;   as  for  instance, 


GENERAL  MANAGEMENT  OF  TEETHING  CHILDREN.  343 

a  mixture  of  the  bicarbonite  of  potash  not  quite  neutralized  with  citric 
acid,  to  each  dose  of  which  two  or  three  minims  of  the  tincture  of 
hyoscyamus  may  be  added,  if  the  child  be  very  restless  and  fretful.1 
The  diet  must  be  carefully  regulated ;  and  as  the  heat  of  the  mouth  may 
induce  the  child  to  suck  too  often,  in  order  to  obtain  the  grateful  relief 
of  moisture,  and  by  so  doing  to  overload  its  stomach,  water  or  barley- 
water  should  be  freely  given  to  it;  and  the  mother  should  be  cautious 
not  to  put  it  too  frequently  to  the  breast.  If  the  child  have  been 
weaned,  still  greater  care  will  be  required,  for  it  will  often  be  found 
that  it  is  no  longer  able  to  digest  its  ordinary  food,  which  either  is  at 
once  rejected  by  the  stomach,  or  else  passes  through  the  intestines 
undigested.  Very  thin  arrow-root  made  with  water,  with  the  addition 
of  one  third  of  milk,  will  suit  in  many  cases;  or  you  may  occasionally 
substitute  for  this,  equal  parts  of  milk  and  water  thickened  by 
dissolving  isinglass  in  it  till  its  consistence  equals  that  of  thick  barley- 
water  ;  or  may  employ  the  white  decoction  of  Sydenham  with  the 
addition  of  one  part  of  milk.  If  the  bowels  be  disordered,  half  a 
grain  of  Dover's  powder  night  and  morning  will  often  restrain  their 
over  action ;  while  the  child  may  take  during  the  day  a  mucilaginous 
mixture,2    containing  small  doses  of  the  vinum  ipecacuanha  and  of 

(No.  21.) 
2  R  Misturae  Acaciae,  ^vj. 

Liquoris  Potassae,  n^xxx. 
Vin.  Ipecacuanha,  nvxxiv. 
Syrupi  Altheae,  %'w. 

Aquas  purae,  gxiij.     M.     giij.  6tis  horis. 
\  For  a  child  from  12  to  18  months  old. 

some  alkali,  as  the  bicarbonate  of  potash  or  the  liquor  potassae.  The 
dysuria  from  which  infants  sometimes  suffer  when  teething  is  relieved 
by  a  similar  plan  of  treatment,  with  the  addition  of  small  doses  of 
castor  oil  if  the  bowels  do  not  act  regularly  ;  while  the  tepid  bath  is 
often  extremely  serviceable  in  diminishing  that  great  heat  of  skin  which 
exists  in  many  of  these  cases. 

That  state  of  the  mouth  in  which  small  aphthous  ulcers  appear  upon 
the  tongue  and  about  the  alveolae  is  usually  connected  with  disorder  of 
the  digestive  organs,  to  the  relief  of  which  our  treatment  must  be  chiefly 
directed.  It  is  seldom  necessary  to  do  more  locally,  than  to  pay  great 
attention  to  cleanse  the  mouth  every  time  after  the  child  has  sucked  or 
taken  food,  and  afterwards  to  apply  to  it  a  solution  of  borax,  in  the 
manner  I  pointed  out  to  you  at  the  commencement  of  this  lecture. 
Now  and  then  the  submaxillary  glands  become  swollen  and  tender 
while  the  infant  is  cutting  some  of  its  teeth ;  but  this  condition 
generally  subsides  of  its  own  accord.  Sometimes,  however,  the 
irritation  extends  to  some  of  the  absorbent  glands  beneath  the  jaw 
or  near  its  angle;  and  in  scrofulous  subjects  they  occasionally  inflame 
and  suppurate.  In  such  children,  too,  strumous  ophthalmia  and 
otorrhcea  are  not  infrequently  excited  by  dentition. 

1  See  Formula  No.  2,  p.  43. 


344  TREATMENT  OF  THE  AFFECTIONS  OF  THE  MOUTH. 

That  severe  form  of  inflammation  of  the  gums  to  which  the  name  of 
Odontitis  has  been  given  sometimes  occasions  great  suffering,  and  may- 
even  endanger  the  child's  life,  though  no  instance  has  come  under  my 
own  notice  in  which  it  proved  actually  fatal.  The  gum-lancet  will  here 
do  no  good  whatever ;  its  employment  would  be  intensely  painful,  and 
that  unhealthy  ulceration  which  attends  the  inflammation  of  the  gums 
would  attack  the  edges  of  the  cut,  and  thus  aggravate  instead  of 
relieving  the  child's  sufferings.  Local  depletion  by  leeches,  however, 
is  extremely  useful  in  such  cases.  Some  writers  have  suggested  that 
the  leeches  should  be  applied  to  the  gum  itself;  but  I  have  always 
contented  myself  with  the  much  easier  plan  of  applying  them  to  the 
angle  of  the  jaw,  and  have  seldom  been  disappointed  in  obtaining  very 
marked  relief  01  all  the  symptoms.  The  diet  must  be  most  carefully 
regulated,  the  state  of  the  bowels  attended  to,  and  a  mildly  antiphlogistic 
plan  of  treatment  adopted,  while  the  borax  lotion  may  be  used  locally 
with  advantage.  There  is,  however,  one  remedy  which  acts  in  the 
various  forms  of  stomatitis  almost  like  a  charm,  and  which  proves 
exceedingly  useful  even  when  inflammation  of  the  mouth  is  associated 
with  the  process  of  teething.  This  remedy,  for  the  introduction  of 
which  into  practice  in  cases  of  stomatitis,  the  profession  is  indebted 
to  Dr.  Hunt,1  is  the  chlorate  of  potash,  which  may  be  given  dissolved 
in  water  and  sweetened,  in  the  dose  of  one  grain  every  four  hours  to 
a  child  a  year  old,  with  almost  a  certainty  of  effecting  a  cure  in  the 
course  of  four  or  five  days. 

In  conclusion,  I  may  just  refer  to  those  eezematous  and  impetiginous 
eruptions  of  the  face  and  scalp  which  often  occur  in  teething  children. 
The  old  prejudice  which  regards  diseases  of  the  skin  appearing  at  this 
time  as  having  in  them  something  salutary,  and  that  consequently  it  is 
not  desirable  to  attempt  their  cure,  is  not  destitute  of  a  certain  founda- 
tion in  fact.  Instances  of  the  sudden  disappearance  of  eruptions  on 
the  scalp  during  the  period  of  dentition,  being  followed  by  serious 
impairment  of  the  general  health,  by  convulsions,  or  by  other  signs  of 
mischief  in  the  brain,  are  far  from  uncommon.  Their  removal,  there- 
fore, must  never  be  attempted  except  by  the  gentlest  means,  while  every 
threatening  of  the  supervention  of  cerebral  congestion,  or  of  more 
serious  disease  of  the  brain,  must  be  most  closely  watched  for  and  most 
vigorously  combated.  Sometimes,  too,  it  will  be  found  that  whenever 
the  cutaneous  affection  has  made  a  certain  advance  towards  cure,  the 
signs  of  other  disease  invariably  appear.  In  such  a  case  it  is  wiser  to 
content  yourselves  with  keeping  the  local  ailment  in  check,  rather  than, 
by  persevering  in  the  attempt  to  cure  it,  to  endanger  in  far  more  serious 
respects  the  welfare  of  the  child. 

1  Medico-Chirurgical  Transactions,  vol.  xxvi.  p.  142. 


INFLAMMATION  OF  THE  MOUTH. 


LECTURE    XXIX. 

Inflammation  or  the  Mouth,  or  Stomatitis— its  three  varieties. 

Follicular  stomatitis — often  a  secondary  affection — most  frequent  before  dentition  is 
completed — its  symptoms — character  of  the  ulceration  of  the  mouth — not  a  serious 
disorder. — Its  treatment. 

Ulcerative  stomatitis — principally  affects  the  gums — its  course  usually  chronic — has  very 
little  tendency  to  degenerate  into  gangrene — Its  treatment — the  chlorate  of  potash 
almost  a  specific  for  it. 

Gangrenous  stomatitis — extremely  rare,  but  very  fatal— essential  differences  between  it 
and  the  other  forms  of  stomatitis — dependent  on  alterations  of  the  blood,  such  as  occur 
in  fevers — its  mode  of  commencement,  symptoms,  and  course — state  of  the  gangrenous 
parts  on  dissection. 

Treatment — importance  of  efficient  cauterization — what  caustics  are  to  be  used,  and  how 
they  are  to  be  applied. 

The  disease  does  not  depend  on  the  administration  of  mercury. 

Cynanche  Tonsillaris — unusual  in  young  children — its  symptoms  not  peculiar. 

Hypertrophy  of  the  Tonsils — its  frequency  and  importance  in  childhood — its  symp- 
toms— extreme  dyspnoea  sometimes  produced  by  it — modifications  it  produces  in  form 
of  mouth  and  nose— deformity  of  chest  resulting  from  it,  how  produced. — Treatment 
— necessity  for  excision  of  tonsils. 

Cynanche  Parotidea — most  common  near  period  of  puberty — epidemic  and  contagious 
— its  symptoms — metastasis  of  inflammation  rare — Treatment. 

Among  the  local  accidents  which  complicate  dentition,  we  noticed  a 
condition  of  the  mucous  membrane  of  the  mouth,  which,  though  not 
attended  by  serious  danger,  is  often  the  source  of  much  suffering  to  the 
patient.         \ 

Inflammation  of  the  mouth,  however,  is  an  occurrence  by  no  means 
confined  to  the  period  of  teething,  but  it  comes  on  in  children  of  all 
ages,  assumes  very  different  forms,  and  leads  to  very  different  results  in 
one  case  from  those  which  characterize  it  in  another.  The  mucous  fol- 
licles of  the  mouth  'are  the  chief  seat  of  the  disease  in  one  case,  the 
substance  of  the  gum  in  another,  that  of  the  cheek  in  a  third.  In  the 
first,  the  affection  issues  in  the  formation  of  several  small  ulcers,  which 
heal  eventually  of  their  own  accord ;  in  the  second,  an  unhealthy  pro- 
cess of  ulceration  destroys  the  gums  and  denudes  the  teeth,  but  it  is 
tardy  in  its  advance,  and  tends  to  a  spontaneous  cure ;  while,  in  the 
last,  mortification  involves  all  the  tissues  of  the  cheek,  and  spreads  with 
a  rapidity  which  remedies  generally  fail  to  check,  and  which  is  arrested 
at  last  only  by  the  patient's  death. 

Each  of  these  varieties  of  stomatitis  requires  from  us  more  than  a 
passing  notice. 

The  first — the  follicular  stomatitis  of  some  writers,  the  aphthous 
stomatitis  of  others,  is  met  with  either  as  a  concomitant  or  sequela  of 
measles,  or  as  an  idiopathic  affection.  In  the  former  case  it  depends 
on  the  extension  to  the  mouth  of  a  state  of  inflammation  similar  to  that 
which  gives  rise  to  the  eruption  on  the  skin ;  in  the  latter,  it  is  often 
associated  with  obvious  gastric  or  intestinal  disorder.  Under  either  of 
these  conditions  it  is  rare  after  five  years  of  age ;  and  though  it  often 
depends  on  causes  quite  independent  of  dentition,  yet  from  the  period 


346  symptoms  or  follicular^stomatitis. 

when  teething  has  commenced,  to  the  end  of  the  third  year,  is  the  time 
of  its  most  common  occurrence.  When  it  constitutes  an  idiopathic 
affection,  more  or  less  fever,  and  restlessness,  loss  of  appetite,  and 
unhealthy  state  of  the  evacuations,  and  frequently  a  relaxed  condition 
of  the  bowels,  precede  the  local  ailment  for  several  days.  Attention 
is  generally  called  to  the  state  of  the  mouth  by  the  child  being  observed 
to  suck,  or  to  take  food,  with  manifest  pain  and  difficulty ;  while  at  the 
same  time  the  secretion  of  saliva  is  greatly  increased,  and  the  submax- 
illary glands  are  swollen  and  tender.  The  mouth  is  hot,  its  mucous 
membrane  generally  of  a  livid  red,  while  a  coat  of  thin  mucus  covers 
the  centre  of  the  tongue.  On  the  surface  of  the  tongue,  especially  near 
its  tip,  on  the  inside  of  the  lips,  particularly  on  the  lower  lip  and  about 
its  fold,  on  the  inside  of  the  cheek,  near  the  angles  of  the  mouth,  and 
less  often  in  other  situations  also,  may  be  seen  several  small  isolated 
transparent  vesicles,  or  the  ulcers  which,  after  bursting,  they  leave 
behind.  The  ulcers  are  small,  of  a  rounded  or  oval  form,  not  very 
deep,  but  having  sharply-cut  edges ;  and  their  surface  is  covered  by  a 
yellowish-white,  firmly-adherent  slough.  When  attention  is  first 
directed  to  the  mouth,  several  of  these  small  ulcerations  usually  exist, 
for  the  vesicular  stage  of  the  affection  appears  to  be  generally  very  short, 
while  the  ulcers  are  indolent,  and  sometimes  continue  for  many  days 
without  shewing  any  disposition  to  heal  or  to  increase  in  size.  The 
eruption  of  a  single  crop  of  vesicles,  and  the  change  of  these  vesicles 
into  minute  ulcerations,  that  heal  in  the  course  of  time,  do  not  complete 
the  history  of  this  affection,  for  while  the  mucous  membrane  in  the 
situation  of  some  of  these  ulcers  at  length  resumes  its  natural  condition, 
other  vesicles  appear,  which  again  degenerate  into  little  ulcers,  and 
thus  keep  up  the  ailment,  sometimes  for  weeks  together.  In  some 
cases,  not  above  five  or  six  of  these  little  ulcers  exist  at  once,  or  they 
may  even  be  less  numerous,  while  it  is  very  seldom  that  more  than 
fifteen  or  twenty  of  them  are  observable  at  one  time.  By  the  successive 
appearance  of  fresh  ulcerations,  and  the  coalescence  of  several,  an 
ulcerated  strip  of  considerable  extent  sometimes  forms,  especially  at  the 
tip  of  the  tongue,  or  on  the  lower  lip.  When  the  ulcers  are  healing  no 
change  in  their  aspect  is  observable,  and  they  continue  to  the  last 
covered  by  the  same  yellow  slough,  but  by  degrees  they  diminish  in 
size ;  and  seldom  or  never  is  any  cicatrix  observable  in  the  situation 
which  they  occupied.  In  some  cases  the  affection  is  complicated  with 
a  herpetic  eruption  about  the  edges  of  the  lips,  the  vesicles  of  which 
degenerate  into  ulcerations  similar  to  those  observed  in  the  interior  of 
the  mouth,  and  by  their  soreness  add  very  much  to  the  sufferings  of 
the  patient. 

Even  though  no  remedies  be  employed,  this  affection  shows  no  ten- 
dency to  rapid  increase,  neither  is  it,  in  general,  associated  with  any 
disposition  to  the  formation  of  false  membrane  in  the  mouth,  still  less 
with  any  tendency  to  gangrene.  It  is  sometimes  a  source  of  much 
annoyance  to  the  child,  but  need  never  excite  any  serious  solicitude, 
except  when  it  occurs  as  a  sequela  of  measles.  In  that  case,  however, 
as  was  observed  some  days  ago,  it  occasionally  becomes  associated  with 
diphtheritic  deposits  on  the  fauces,  and  with  ulcerative  inflammation  of 


ULCERATIVE  STOMATITIS,  OR  NOMA.  347 

the  larynx,  though  our  anxiety  is  then  excited  less  by  the  affection 
itself  than  by  its  concomitants. 

In  the  treatment  of  this  affection,  our  attention  must  be  chiefly 
directed  to  correcting  the  gastric  and  intestinal  disorder  by  which  it  is 
accompanied  ;  and  when  this  object  has  been  attained,  the  local  ailment 
in  many  cases  speedily  subsides.  The  borax  lotion  mentioned  in  the 
last  lecture  is  one  of  the  best  local  applications  that  can  be  used ;  but 
if  the  ulcerations  shew  no  tendency  to  heal,  it  may  be  desirable  to 
touch  them  once  or  twice  a  day  with  a  solution  of  five  grains  of  nitrate 
of  silver  in  an  ounce  of  distilled  water. 

Between  the  mild  affection  we  have  just  been  studying,  and  the  second 
form  of  stomatitis,  to  the  examination  of  which  we  are  now  about  to 
pass,  there  are  comparatively  few  points  of  resemblance.  This  variety 
of  the  disease  attacks  the  gums,  and  sometimes  destroys  them  exten- 
sively, unlike  the  former  ailment,  which,  even  though  it  should  continue 
long,  seldom  occasions  any  actual  loss  of  substance.  The  process, 
however,  by  which  the  destruction  of  the  gums  is  accomplished  is  one 
of  ulceration,  not  of  mortification — a  fact  which  it  is  of  importance  to 
bear  in  mind,  lest  we  should  fall  into  the  error  of  some  observers,  who 
have  confounded  together  under  the  name  of  Cancrum  Oris,  both  this 
affection  and  that  more  formidable  malady,  true  gangrene  of  the  mouth. 
To  preserve  the  distinction  between  the  two  diseases,  it  may  be  well, 
following  the  example  of  some  writers,  to  apply  to  the  former  the 
designation  of  Ulcerative  Stomatitis,  or  Noma,1  and  to  the  latter  that 
of  gangrenous  stomatitis,  or  gangrene  of  the  mouth. 

It  is  by  no  means  a  constant  occurrence  for  any  special  derangement 
of  the  general  health  to  precede  the  attack  of  ulcerative  stomatitis, 
though  the  children  who  are  affected  by  it  are  seldom  robust,  and  in 
many  instances  are  such  as  have  suffered  from  deficient  food,  or  a  damp 
unhealthy  lodging,  or  both.  In  children  who  are  not  very  carefully 
tended,  the  ulceration  has  sometimes  made  considerable  progress  before 
its  existence  is  suspected,  and  the  profuse  flow  of  the  saliva,  or  the 
offensive  smell  of  the  breath,  is  the  circumstance  which  at  length  excites 
attention.  Coupled  with  these  symptoms,  too,  there  is  often  considera- 
ble swelling  of  the  upper  lip,  and  the  submaxillary  glands  are  frequently 
swollen  and  painful.  On  opening  the  mouth,  the  gums  are  seen  to  be 
red,  and  swollen  and  spongy,  and  their  edge  is  covered  with  a  dirty 
white,  or  greyish,  pultaceous  deposit,  on  removing  which  their  surface 
is  exposed,  raw,  and  bleeding.  At  first,  only  the  front  of  the  gum  is 
thus  affected;  but  as  the  disease  advances,  it  creeps  round  between  the 
teeth  to  their  posterior  surface,  and  then,  destroying  the  gum  both  in 
front  and  behind  them,  leaves  them  denuded,  and  very  loose  in  their 
sockets ;  but  it  is  not  often  that  they  actually  fall  out.  The  gums  of  the 
incisor  teeth  are  usually  first  affected  :  those  of  the  lower  jaw  more 
frequently  and  more  extensively  than  those  of  the  upper;  but  if  the 
disease  be  severe,  the  gums  at  the  side  of  the  mouth  become  likewise 
involved,  though  it  is  seldom  that  the  two  sides  suffer  equally.     Some- 

1  From  voftcu  ?  used  by  Hippocrates  with  reference  to  putrid  and  eroding  ulcers.  See 
Foesius,  (Economia  Hippocratis,  p.  432. 


348  ITS  SYMPTOMS. 

times  aphthous  ulcers,  like  those  of  follicular  stomatitis,  are  seen  on  the 
inside  of  the  mouth  in  connection  with  this  state  of  the  gums ;  but 
oftener  it  exists  alone.  On  those  parts  of  the  lips  and  cheeks,  however, 
which  are  opposite  to,  and  consequently  in  contact  with,  the  ulcerated 
gums,  irregular  ulcerations  form,  which  are  covered  with  a  pultaceous 
pseudo-membranous  deposit,  similar  to  that  which  exists  on  the  gums 
themselves.  Sometimes,  too,  deposits  of  false  membrane  take  place  on 
other  parts  of  the  inside  of  the  mouth,  the  surface  beneath  being  red, 
spongy,  and  bleeding,  though  not  distinctly  ulcerated.  If  the  disease 
be  severe  and  long-continued,  the  tongue  assumes  a  sodden  appearance, 
and  is  indented  by  the  teeth,  and  the  cheek,  on  one  or  other  side,  is 
somewhat  swollen,  while  the  saliva,  though  rather  less  abundantly  secreted 
than  at  the  commencement  of  the  affection,  continues  horribly  foetid, 
axnd  is  often  streaked  with  blood,  the  gums  themselves  bleeding  on  the 
slightest  touch.  But  even  if  left  alone,  the  affection  usually  subsides 
in  the  course  of  time,  though  it  may  continue  almost  stationary  for  days 
or  weeks  together,  and  this  notwithstanding  that  the  general  health  is 
tolerably  good.  It  would  be  too  much  to  say  that  this  unhealthy 
ulceration  never  degenerates  into  gangrene :  but  though  a  very  large 
number  of  cases  of  ulcerative  stomatitis  have  come  under  my  notice,  I 
have  seen  only  one  instance  in  which  it  was  succeeded  by  true  gangrene 
of  the  mouth.  When  recovery  has  commenced,  the  disease  ceases  to 
spread  ;  the  drivelling  of  foetid  saliva  diminishes ;  the  white  pultaceous 
deposit  on  the  gums,  or  on  the  ulcerations  of  the  cheek  or  lips,  becomes 
less  abundant ;  the  ulcers  themselves  grow  smaller ;  and,  finally,  the 
gums  become  firm,  and  their  edges  of  a  bright  red,  though  still  for  a 
long  time  shewing  a  disposition  to  become  once  more  the  seat  of  the 
ulcerative  process,  and  continuing  for  a  still  longer  time  to  cover  the 
teeth  but  very  imperfectly. 

Various  internal  remedies  and  local  applications  have  been  at  different 
times  recommended  for  the  cure  of  this  affection.  Tonics  have  been 
much  employed,  and  the  supposed  analogy  between  this  state  of  the 
gums  and  that  which  exists  in  scurvy,  has  led  practitioners  to  give  the 
preference  to  remedies  reputed  to  be  possessed  of  antiscorbutic  proper- 
ties. Lotions  of  alum,  or  the  burnt  alum  in  substance,  or  the  chloride 
of  lime  in  powder,  have  all  been  used  locally  with  more  or  less  benefit. 
It  was  my  custom  also  to  prescribe  these  remedies  in  cases  of  ulcerative 
stomatitis;  but  since  I  became  acquainted  with  the  virtues  of  the  chlo- 
rate of  potash,  I  have  learnt  to  rely  upon  it  almost  exclusively.  It 
appears,  indeed,  almost  to  deserve  the  name  of  a  specific  in  this  affec- 
tion ;  for  a  marked  improvement  seldom  fails  to  be  observed  in  the 
patient's  condition  after  it  has  been  administered  for  two  or  three  days  ; 
and  in  a  week  or  ten  days  the  cure  is  generally  complete.  Three  grains 
every  four  hours,  dissolved  in  water,  and  sweetened,  is  a  sufficient  dose 
for  a  child  three  years  old ;  and  five  grains  every  four  hours  is  the 
largest  quantity  that  I  have  administered  to  a  child  of  eight  or  nine. 
If  the  bowels  be  constipated,  a  purgative  should  be  previously  adminis- 
tered ;  but  there  seems  to  be  no  form,  nor  any  stage  of  the  affection,  in 
which  the  chlorate  of  potash  is  not  useful.  The  diet  should  be  light 
but  nutritious,  and  quinine  or  other  tonics  are  sometimes  serviceable  if 


GANGRENOUS  STOMATITIS.  349 

the  child's  health  should  continue  feeble  after  the  local  malady  has 
been  cured. 

Ulcerative  stomatitis  is  an  affection  of  such  frequent  occurrence,  that 
many  instances  of  it  come  under  my  notice  every  year,  especially  during 
the  damp  autumnal  months ;  while  it  is  attended  with  so  little  danger, 
that  the  only  case  which  I  have  known  to  prove  fa'al  was  one  in  which 
gangrene  of  the  mouth  supervened  upon  it.  Gangrenous  stomatitis, 
on  the  other  hand,  is  a  disease  so  rare,  that  I  have  only  six  times  had 
the  opportunity  of  witnessing  it ;  but  so  fatal,  that  in  five  out  of  those 
six  cases  the  patients  died.  The  larger  experience  of  other  observers 
shows  an  almost  equally  unfavourable  result,  since  twenty  out  of  twenty- 
one  cases  that  came  under  the  notice  of  MM.  Rilliet  and  Barthez  had 
a  fatal  termination ;  and  a  recent  French  writer,1  who  has  collected 
from  different  sources  239  cases,  which  did  not  all  occur  in  children, 
states  that  176  of  the  number,  or  75  per  cent,  terminated  fatally.  The 
formidable  nature  of  the  disease  requires  that  we  study  it  more  closely, 
than,  considering  the  rarity  of  its  occurrence,  would  otherwise  be  neces- 
sary ;  and  it  is  the  more  important  to  do  so,  in  order  that  we  may 
avoid  the  not  very  uncommon  error  which  confounds  this  dangerous 
affection  with  that  comparatively  trifling  ailment — ulcerative  stoma- 
titis. 

The  constitutional  disturbance  which  often  precedes  the  other  two 
affections  of  the  mouth  that  we  have  just  been  studying,  was  seen  to  be 
generally  of  a  trivial  nature,  and  never  so  severe  as  to  excite  serious 
anxiety.  Gangrene  of  the  mouth,  on  the  other  hand,  seldom  comes  on, 
except  in  children  whose  health  has  been  already  much  impaired  by 
previous  disease,  and  especially  by  such  diseases  as  are  connected  with 
important  changes  in  the  circulating  fluid.  In  strict  propriety,  indeed, 
I  doubt  whether  we  ought  not  to  remove  both  this  and  those  other 
allied  affections,  in  which  the  skin  or  the  genital  organs  become  the 
seat  of  gangrene,  from  among  the  class  of  local  ailments,  and  refer 
them  to  the  category  of  blood  diseases.  Of  twenty-nine  cases  of  gan- 
grene of  the  mouth,  which  MM.  Rilliet  and  Barthez  either  observed 
themselves,  or  of  which  they  found  mention  in  the  writings  of  other 
physicians,  only  one  appeared  to  be  an  instance  of  the  disease  in  an 
idiopathic  form ;  while  in  twelve  cases  it  followed  an  attack  of  measles. 
Of  the  six  cases  which  I  have  observed,  and  three  of  which  I  examined 
after  death,  two  succeeded  to  typhoid  fever,  two  to  measles,  one  came 
on  in  a  child  whose  health  had  been  completely  broken  down  by  ague, 
and  one  supervened  in  a  tuberculous  child,  who  had  been  affected  for 
many  weeks  with  ulcerative  stomatitis  in  a  severe  form.  Though  not 
confined  to  any  one  period  of  childhood,  gangrene  of  the  mouth  is  more 
frequent  between  the  ages  of  two  and  five  than  either  earlier  or  later. 
Of  the  six  cases  that  came  under  my  own  observation,  two  were  in 
children  between  two  and  three  years  old,  one  in  a  child  aged  three, 
one  between  four  and  five,  one  at  six  and  a  quarter,  and  one  at  eight 
years  of  age.  Of  the  twenty-nine  cases  mentioned  by  MM.  Rilliet  and 
Barthez,  nineteen  occurred  between  two  and  five ;  ten  between  six  and 

1  Tourdes,  Du  Noma,  &c.  4to.     Thfese  de  Strasbourg,  1848. 


850  ITS    SYMPTOMS. 

twelve ;  and  M.  Tourdes'1  comparison  of  102  cases  between  one  and  a 
half  and  twelve  years,  likewise  yields  the  greatest  number  during  the 
third  and  fourth  years. 

Although  all  the  tissues  of  the  cheek  become  involved  in  the  course 
of  this  affection,  yet  difference  of  opinion  has  existed  with  reference  to 
the  part  in  which  it  commences ;  some  observers  conceiving  that  it 
usually  begins  in  the  substance  of  the  cheek,  while  others  regard  the 
mucous  membrane  as  being  the  part  which  is  invariably  the  first 
attacked.  So  far  as  my  own  observation  enables  me  to  judge,  I  am 
disposed  to  regard  this  latter  view,  which  is  that  of  MM.  Rilliet  and 
Barthez,  and  of  M.  Baron,  and  which  is  moreover  supported  by  the 
recent  minute  researches  of  Professor  Albers,2  of  Bonn,  as  generally  cor- 
rect. At  the  same  time,  however,  I  must  admit  that  I  have  had  no  very  re- 
cent opportunity  of  personally  investigating  this  subject,  while  a  very  com- 
petent observer,  Dr.  Loschner,3  physician  to  the  Children's  Hospital  at 
Prague,  while  he  admits  the  occasional  commencement  of  the  affection 
in  either  way,  believes  the  former  to  be  the  more  common.  According 
to  his  observations,  the  appearance  of  a  swelling,  having  a  hard  central 
spot  or  nucleus,  surrounded  by  tense,  elastic,  but  less  firm  tissue, 
gradually  passing  off  into  the  texture  of  the  adjacent  parts,  is  the  first 
step  in  the  process  ;  ulceration  of  the  mucous  membrane  being  secondary 
to  this  peculiar  infiltration  of  the  cellular  tissue  of  the  cheek.  It  is, 
indeed,  very  probable  that  the  gangrene  sometimes  begins  in  the  one 
way  and  sometimes  in  the  other ;  while  any  dispute  concerning  it 
loses  almost  all  its  practical  moment,  if  we  regard  this  and  other  forms 
of  gangrene  as  resulting  from  merely  accidental  differences  in  the 
mode  in  which  the  graver  deterioration  of  the  circulating  fluid  manifests 
itself. 

The  early  stages  of  the  affection  are  attended  by  scarcely  any  suffer- 
ing, owing  to  which,  as  well  as  to  the  circumstance  that  the  children  in 
whom  it  supervenes  are  almost  always  labouring  under  some  other  dis- 
ease, or  in  the  course  of  convalescence  from  it,  it  is  probably  due  that 
the  malady  is  often  not  discovered  until  after  it  has  made  considerable 
progress.  There  may  for  a  day  or  two  have  been  an  unusual  foetor  of 
the  breath,  and  a  profuse  secretion  of  offensive  saliva ;  but  the  appear- 
ance of  swelling  of  the  cheek  is  frequently  the  first  symptom  that  leads 
to  a  careful  examination  of  the  state  of  the  mouth.  The  characters  of 
the  swelling  of  the  cheek  are  almost  pathognomonic  of  gangrene  of  the 
mouth.  It  is  not  a  mere  puffiness  of  the  integument,  unaccompanied 
with  any  change  of  its  colour,  such  as  is  sometimes  observed  in  ulcera- 
tive stomatitis;  but  the  cheek  is  tense,  and  red,  and  shining, — it  looks 
as  if  its  surface  had  been  besmeared  with  oil,  and  in  the  centre  of  the 
swollen  part  there  is  generally  a  spot  of  a  brighter  red  than  that  around. 
The  cheek  feels  hard,  and  is  often  so  unyielding,  that  the  mouth  cannot 
be  opened  wide  enough  to  get  a  good  view  of  its  interior.  The  disease 
is  almost  always  limited  to  one  side,  and  generally  to  one  cheek.  Some- 

1  Op.  cit.  p.  31. 

2  Archiv  f.  physiol.  Heilkunde,  ix.  7-8,  1850  ;  and  Schmidt's  Jahrb.  1851,  No.  2,  p.  195. 

3  Der  Brand  ?ui  Kindesalter,  in  the  Viertejahrschrift  fiir  die  praxt.  Heilkunde,  Vol. 
xv.  p.  85. 


SYMPTOMS  OF   GANGRENOUS  STOMATITIS.  351 

times,  however,  it  extends  to  the  lower  lip ;  and  occasionally  it  begins 
in  that  situation.  The  upper  lip  is  now  and  then  reached  by  the  pro- 
gress of  the  disease,  but  is  never  its  primary  seat.  Whatever  be  the 
situation  of  the-  external  swelling,  there  will  generally  be  found  within 
the  mouth,  at  a  point  corresponding  to  the  bright  red  central  spot,  a 
deep  excavated  ulcer,  with  irregular  jagged  edges,  and  a  surface  covered 
by  a  dark  brown  shreddy  slough.  The  gums  opposite  to  the  ulcer  are 
of  a  dark  colour,  covered  with  the  putrilage  from  its  surface,  and  in 
part  destroyed,  leaving  the  teeth  loose,  and  the  alveolae  denuded. 
Sometimes,  especially  if  the  disease  be  further  advanced,  no  single  spot 
of  ulceration  is  recognizable,  but  the  whole  inside  of  the  cheek  is  occu- 
pied by  a  dirty  putrilage,  in  the  midst  of  which  large  shreds  of  dead 
mucous  membrane  hang  down.  As  the  disease  extends  within  the 
cheek,  a  similar  process  of  destruction  goes  on  upon  the  gum ;  the 
loosened  teeth  drop  out  one  by  one,  and  the  alveolar  process  of  the  jaw 
loses  its  vitality  for  a  more  or  less  considerable  extent;  while  some- 
times, though  of  this  I  have  not  seen  any  instance,  a  portion  of  the 
ramus  of  the  jaw  itself  becomes  necrosed.  The  saliva  continues  to  be 
secreted  profusely,  but  shows  by  the  changes  which  take  place  "in  its 
characters  the  progress  of  the  disease.  At  first,  though  remarkable  for 
its  fcetor,  it  is  otherwise  unaltered ;  but  afterwards  it  loses  its  trans- 
parency, and  receives  from  the  putrefying  tissues  over  which  it  passes, 
a  dirty,  greenish,  or  brownish  colour,  and  at  the  same  time  acquires  a 
still  more  repulsive  odour. 

While  the  gangrene  is  thus  going  on  inside  the  mouth,  changes  no 
less  remarkable  are  taking  place  on  the  exterior  of  the  face.  The  red- 
ness and  swelKng  of  the  cheek  extend,  and  the  deep  red,  central  spot, 
grows  larger.  A  black  point  appears  in  its  midst;  at  first  it  is  but  a 
speck,  but  it  increases  rapidly,  still  retaining  a  circular  form  ;  it  attains 
the  bigness  of  a  sixpence,  a  shilling,  a  half  crown,  or  even  a  larger  size. 
A  ring  of  intense  redness  now  encircles  it,  the  gangrene  ceases  to 
extend,  and  the  slough  begins  to  separate.  Death  often  takes  place 
before  the  detachment  of  the  eschar  is  complete,  and  it  is  fortunate 
when  it  does  so,  for  sloughing  usually  commences  in  the  parts  left  behind. 
The  interior  of  the  mouth  is  now  exposed ;  its  mucous  membrane  and 
the  substance  of  the  cheek  hang  down  in  shreds  from  amidst  a  blacken- 
ing mass,  and  form  one  of  the  most  loathsome  spectacles  that  can  be 
conceived;  while  the  horrible  stench  which  the  mortified  parts  spread 
around,  makes  the  task  of  watching  the  poor  child  as  repulsive  as  it  is 
distressing. 

Happily  it  is  not  often  that  acute  suffering  of  the  child  occurs  to 
heighten  the  distress  of  the  sad  scene.  Usually  the  patient  has  but 
little  pain  from  the  very  first,  but  is  generally  more  drowsy  than  natural, 
though  sometimes  the  nights  are  restless ;  and  in  those  cases  in  which 
gangrene  of  the  mouth  supervened  in  the  course  of  typhoid  fever,  the 
delirium  which  existed  before  continued  unmodified.  The  pulse  grows 
feebler  as  the  disease  advances;  but  gleams  of  cheerfulness  may  some- 
times be  perceived,  even  long  after  the  appearance  of  the  black  eschar 
on  the  cheek  has  shown  the  case  to  be  all  but  hopeless ;  and  the  desire 
for  food  often  continues  unabated,  till  within  a  few  hours  of  the  child's 


852  SYMPTOMS  OF  GANGRENOUS  STOMATITIS. 

death,  which  generally  takes  place  quietly,  though  sometimes-  it  is  pre- 
ceded by  convulsions. 

Since  gangrene  of  the  mouth  occurs  in  the  course  of  a  great  variety 
of  diseases,  the  only  morbid  appearances  characteristic  of  it  are  those 
which  result  from  the  local  mischief.  On  two  occasions  I  dissected  the 
gangrenous  parts  very  carefully,  and  the  alterations  which  presented 
themselves  to  my  notice  were  precisely  the  same  as  have  been  described 
by  MM.  Rilliet  and  Barthez.  The  absorbent  glands,  both  superficial 
and  deep-seated,  on  the  affected  side,  are  enlarged,  and  the  cellular 
tissue  of  the  cheek  is  infiltrated  with  serum,  which  is  more  abundant  the 
nearer  one  approaches  to  the  slough.  In  the  substance  of  the  eschar 
the  distinction  of  parts  is  no  longer  easy,  but  with  care  the  vessels  and 
nerves  may  still  be  traced ;  and  the  reason  why  fatal  haemorrhage  so 
seldom  cuts  short  the  life  of  patients  suffering  from  this  affection,  is 
at  once  explained  by  the  clot  which  plugs  up  the  vessels  for  some  dis- 
tance on  either  side  of  the  gangrenous  mass.  On  one  occasion  I  found 
the  root  of  the  tongue,  the  tonsils,  pharynx,  both  surfaces  of  the  epi- 
glottis, and  about  an  inch  of  the  oesophagus,  completely  coated  with  a 
moderately  firm,  yellow  false  membrane,  about  a  line  in  thickness,  easily 
detached,  and  leaving  the  subjacent  mucous  membrane  only  a  little 
redder  than  natural.  A  few  patches  of  a  similar  deposit  existed  in  the 
larynx,  but  not  continuous  with  that  in  the  pharynx.  In  this  case, 
great  difficulty  of  deglutition  had  existed  for  three  days  before  the 
death  of  the  child.  The  association  of  diphtheritis  with  gangrene  of 
the  mouth,  is,  however,  an  accidental  complication,  and  one  of  not  very 
frequent  occurrence. 

The  arrest  of  the  sloughing  is  the  one  point  to  which  in  the  treatment 
of  this  affection  the  attention  of  all  practitioners  has  been  directed.  The 
small  amount  of  success  which  has  attended  their  efforts  is  partly  attri- 
butable to  the  circumstance  that  the  affection  has  frequently  been  over- 
looked until  it  has  already  made  considerable  progress ;  in  part  also  to 
the  fact  that  when  recognised,  the  local  remedies  employed  in-order  to 
check  the  gangrene  have  either  been  too  mild,  or  have  been  applied  with 
too  timorous  a  hand.  Unfortunately,  too,  there  is  considerable  difficulty 
in  applying  any  caustic  effectually  to  the  interior  of  the  mouth;  for  not 
only  does  the  tense  and  swollen  condition  of  the  cheek  prevent  our 
obtaining  easy  access  to  the  gangrenous  parts,  but  the  child  naturally 
resists  an  operation  which  cannot  but  occasion  it  most  severe  pain. 
Ineffectual  cauterization,  however,  is  useless,  or  worse  than  useless ;  and 
though  every  endeavour  should  be  made  to  prevent  the  needless  destruc- 
tion of  healthy  parts,  yet  of  the  two  evils,  that  of  doing  too  much  is 
unquestionably  less  than  that  of  doing  too  little.  It  is  of  importance, 
moreover,  not  only  that  the  cauterization  should  be  done  effectually,  but 
also  that  it  should  be  practised  early.  M.  Baron,  indeed,  speaks  of 
incising  the  slough  in  the  cheek,  and  then  applying  the  actual  cautery 
to  the  part ;  but  I  am  not  aware  of  any  instance  in  which  this  suggestion 
has  been  acted  on  with  a  good  result.  When  once  the  mortification  has 
extended  through  the  substance  of  the  cheek,  the  chances  of  arresting 
its  progress  must  be  very  few.  As  the  sloughing  advances  from  within 
outwards,  it  is  to  the  interior  of  the  mouth  that  our  remedies  must  be 


TREATMENT   OF   GANGRENOUS   STOMATITIS.  853 

applied ;  and  since  the  advance  of  the  disease  is  too  rapid  to  allow  of 
our  trying  mild  means  at  first,  and  afterwards  resorting,  if  necessary, 
to  such  as  are  more  powerful,  we  must  employ  an  agent  sufficiently 
energetic  at  once  to  arrest  its  progress.     "Various  caustics  have  been 
recommended  for  this  purpose,  but  none  appear  to  be  so  well  fitted  to 
accomplish  it  as  the  strong  hydrochloric  or  nitric  acid.     I  am  accus- 
tomed to  employ  the  latter,  applying  it  by  means  of  a  bit  of  sponge,  or 
of  soft  lint  or  tow,  fastened  to  a  quill,  while  I  endeavour,  by  means  of 
a  spoon  or  spatula,  to  guard  the  tongue,  and  other  healthy  parts,  as  far 
as  possible,  from  the  action  of  the  acid.     In  the  only  case  that  I  saw 
recover,  the  arrest  of  the  disease  appeared  to  be  entirely  owing  to  this 
agent ;  and  though  the  alveolar  processes  of  the  left  side  of  the  lower 
jaw,  from  the  first  molar  tooth  backwards,  died,  and  exfoliated,  appa- 
rently from  having  been  destroyed  by  the  acid,  yet  it  must  be  owned 
that  life  was  cheaply  saved  even  at  that  cost.     Some  increase  of  the 
swelling  of  the  cheek  almost  invariably  follows  the  application  of  this 
agent — a  circumstance  which  may  at  first  occasion  unfounded  apprehen- 
sion lest  the  disease  be  worse.     Twelve  hours,  however,  must  not  be 
allowed  to  elapse,  without  the  mouth  being  carefully  examined,  in  order 
to  ascertain  whether  the  disease  has  really  been  checked,  or  whether 
there  is  any  appearance  of  mortification  in  the  parts  beyond  the  yellow 
eschar  left  by  the  first  application  of  the  acid.     The  cauterization  may 
now  be  repeated,  if  it  appear  necessary,  and  even  though  the  disease 
had  seemed  completely  checked;  yet  reliance  must  not  be  placed  on  the 
improvement  continuing,  but  the  mouth  must  be  examined  every  twelve 
hours,  for  fear  the  mortification  should  spread  unobserved.     During  the 
whole  progress  of  the  case  the  mouth  must  be  syringed  frequently  with 
warm  water,  or  with  camomile  tea  mixed  with  a  small  quantity  of  the 
solution  of  chloride  of  lime,  in  order  to  free  it  from  the  putrid  matters 
that  collect  within  it,  and  to  diminish  as  much  as  possible  their  offensive 
odour.     Should  the  case  go  on  well,  the  frequent  repetition  of  the  strong 
acid  will  be  unnecessary ;  but  the  surface  may  still  require  its  applica- 
tion in  a  diluted  form,  or  it  may  suffice  to  syringe  the  mouth  frequently 
with  a  chloride  of  lime  lotion,  or  to  apply  the  chloride  in  powder  onca 
or  twice  a  day,  according  to  the  suggestion  of  MM.  Billiet  and  Barthez. 
In  the  last  two  cases  of  this  affection  that  came  under  my  notice,  I  like- 
wise employed  the  chloride  of  potash  internally,  but  it  did  not  appear 
to  exert  any  influence  over  it:   and  valuable  though  the  remedy  is  in 
ulcerative  stomatitis,  yet  I  should  scarcely  feel  disposed  to  rely  upon  it, 
to  the  exclusion  of  local  treatment,  in  true  gangrene  of  the  mouth.    Two 
cases,  however,  of  cancrum  oris  succeeding  to  fever,  in  children  of  twelve 
and  thirteen  years  of  age,  were  recently  treated  with  most   complete 
success  by  Dr.  Burrows,  in  St.  Bartholomew's  Hospital,  without  the 
employment  of  any  other  local  measures  than  a  chloride  of  soda  gargle; 
but  with  good  diet,  wine,  and  chlorate  of  potash,  in  doses  of  ten  grains 
every  four  hours. 

During  the  whole  course  of  treatment  you  have  another  indication  to 
fulfil — namely,  to  support  your  patient's  strength  by  nutritious  diet, 
and  by  the  employment  of  wine  and  other  stimulants,  and  by  the 
administration  of  quinine,  or  of  the  extract  or  tincture  of  bark,  or 

23 


354  MERCURY   SELDOM   CAUSES   GANGRENE   OF   THE   MOUTH. 

whatever  form  of  tonic  may  seem  best  suited  to  the  peculiarities  of  the 
case. 

In  conclusion,  let  me  remind  you  that  during  the  whole  progress  of 
the  case  your  prognosis  must  be  regulated  by  the  state  of  the  local 
disease,  rather  than  by  the  urgency  of  the  general  symptoms.  So  long 
as  the  sloughing  is  unchecked,  the  affection  is  tending  rapidly  to  a  fatal 
issue,  and  this  even  though  the  pulse  be  not  very  feeble,  though  the 
appetite  be  good,  and  the  child  still  retain  some  show  of  cheerfulness. 

It  might  seem  to  you  to  be  an  omission  on  my  part,  if  I  left  the 
subject  of  inflammation  and  gangrene  of  the  mouth,  without  some 
notice  of  the  supposed  influence  of  mercury  in  its  production.  There 
can  be  no  doubt  but  that  this  preparation,  even  when  given  in  small 
doses,  has  in  a  few  instances  produced  severe  ptyalism,  inflammation  of 
the  mouth,  loss  of  the  teeth,  and  necrosis,  more  or  less  extensive,  of 
the  lower  jaw.  In  some  cases,  too,  the  inflammation  has  terminated  in 
gangrene  of  the  cheek  which  has  presented  many  of  the  characters  that 
we  have  just  been  noticing ;  and  under  such  circumstances  inquests 
have  sometimes  been  held,  and  blame  has  been  attached  to  the  medical 
attendant  for  alleged  want  of  caution  in  the  administration  of  so  pow- 
erful an  agent  as  mercury.  Now,  although  mercury  should  never  be 
given  without  necessity,  nor  its  administration  continued  without 
watching  its  effects  most  carefully,  yet  I  cannot  but  regard  the  super- 
vention of  gangrene  of  the  mouth  during  its  use  as  merely  an  accidental 
coincidence,  or  else  as  the  result  of  some  peculiar  idiosyncrasy  of  the 
patient,  such  as  has  been  observed  in  the  adult  as  well  as  in  the  child. 
More  than  16,000  children,  of  all  ages,  came  under  my  care  during  the 
period  of  my  connection  with  the  Children's  Infirmary,  and  I  adminis- 
tered mercury  to  any  of  them  who  seemed  to  require  it,  but  hardly  ever 
saw  salivation  follow  its  employment  before  the  completion  of  the  first 
dentition ;  and  never  observed  that  medicine,  at  any  age,  produce  an 
affection  of  the  mouth  sufficiently  serious  to  cause  me  a  moment's 
anxiety. 

An  inconvenience, — I  do  not  know  that  it  deserves  a  more  serious 
designation, — inseparable  from  the  arrangement  of  subjects  which  I 
have  adopted,  is  that  we  pass  at  once  from  diseases  that  are  very 
hazardous,  to  others  which  are  of  a  comparatively  trifling  character,  or 
are  the  sources  of  discomfort  rather  than  of  severe  suffering.  Of  this 
some  of  the  ailments  which  remain  for  our  consideration  to-day  are  no 
inapt  illustrations. 

Inflammation  of  the  soft  palate,  tonsils,  and  fauces,  constituting 
Cynanche  Tonsillar  es,  is  not  strictly  limited  to  any  age,  nor  attended 
with  any  special  symptoms  when  it  occurs  in  the  child.  It  is,  however, 
comparatively  rare  under  12  years  of  age,  and  is  almost  always  less 
severe  than  at  or  after  puberty,  while  I  scarcely  remember  to  have  met 
with  it  under  5  years  of  age, — a  circumstance  which  attaches  special 
importance  to  sore-throat  in  young  children,  since  it  will  usually  be 
found  to  betoken  the  approach  of  scarlet  fever  rather  than  the  exist- 
ence of  simple  inflammation  of  the  tonsils. 

But,  though  acute  inflammation  of  the  tonsils  is  unusual  in  early 
childhood,  a  sort  of  chronic  inflammation  of  those  glands,  which  leads  to 


HYPERTROPHY   OF   THE   TONSILS.  355 

their  very  considerable  enlargement,  is  far  from  uncommon ;  and  this 
hypertrophy  of  the  tonsils,  which,  in  the  adult,  is  little  more  than  an 
inconvenience,  is,  in  the  child,  not  infrequently  the  cause  of  more  serious 
evils.  It  is  seldom  traceable  to  any  acute  attack  of  angina,  but  usually 
comes  on  in  children  who  are  out  of  health,  feeble  and  strumous;  or 
takes  places  slowly  during  the  latter  stages  of  the  first  dentition,  the 
irritation  of  which  appears  in  some  cases  to  be  its  only  exciting  cause. 

Unless  accidentally  discovered,  the  enlargement  of  the  tonsils  has 
usually  become  very  considerable  before  it  attracts  much  notice,  and 
hence  it  is  comparatively  seldom  observed  in  children  under  3  years  old, 
though  M.  Robert,  a  French  surgeon,1  who  has  written  a  very  excellent 
paper  on  the  subject,  speaks  of  having  noticed  it  as  early  as  the  sixth 
month. 

One  of  the  first  symptoms  that  attracts  attention  is  the  habitually 
loud  snoring  of  the  child  during  sleep,  owing  to  the  enlarged  tonsils 
pressing  up  the  velum,  and  thus  obstructing  the  passage  of  air  through 
the  posterior  nares,  while  at  the  same  time  the  voice  becomes  thick ; 
and  both  of  these  symptoms  are  remarkably  aggravated  during,  and  for 
some  time  after,  even  sligbt  attacks  of  catarrh.  An  amount  of  enlarge- 
ment of  the  tonsils  sufficient  to  cause  these  symptoms  is  by  no  means 
uncommon,  and  if  it  do  not  exceed  this  extent  the  inconvenience  to 
which  it  gives  rise  will  in  general  disappear  altogether  with  the  develop- 
ment of  the  mouth  and  vocal  organs  at  the  period  of  puberty.  Often, 
however,  it  is  more  considerable,  and  then  the  tonsils  produce  a  degree 
of  deafness,  partly  by  actual  pressure  on  the  Eustachian  tubes,  partly 
by  the  state  of  habitual  congestion  which  they  occasion  in  the  parts 
in  their  neighbourhood  ;  the  respiration,  moreover,  becomes  rather 
laboured,  and  the  child  has  a  constant  hacking  cough,  occasionally 
aggravated  and  paroxysmal, — two  symptoms  which  I  have  known  to 
raise  on  more  than  one  occasion  an  unfounded  apprehension  of 
phthisis;  and  to  lead  in  others,  where  some  phthisical  disease  actually 
existed,  to  the  expression  of  a  more  gloomy  prognosis  than  was  war- 
ranted by  the  amount  of  mischief  in  the  lungs.  Now  and  then  the 
difficulty  of  respiration  from  mere  enlargement  of  the  tonsils  has  been 
so  considerable  as  to  threaten  life.  No  instance  of  this,  indeed,  has 
come  under  my  own  observation,  but  my  friend  and  former  colleague, 
Mr.  Shaw,  once  had  a  little  boy  under  his  care,  who,  in  addition  to 
constant  dyspnoea,  suffered  from  occasional  fits  of  suffocation  arising 
from  this  cause;  and  one  of  these  fits  was  so  severe  that  in  order  to 
preserve  the  child's  life  it  was  necessary  to  perform  laryngotomy. 

The  long  existence  of  considerable  enlargement  of  the  tonsils,  and  the 
consequent  almost  complete  obstruction  to  the  passage  of  air  through 
the  nostrils,  give  rise  to  a  peculiar  alteration  in  the  form  of  the  parts 
thus  thrown  out  of  use.  The  nostrils  become  extremely  small,  narrow, 
and  compressed ;  and  the  peculiar  character  which  the  physiognomy 
thus  acquires  is  further  increased  by  the  accompanying  modification  in 
the  development  of  the  upper  jaw.  The  superior  dental  arch  remains 
very  narrow,  so  as  not  to  allow  adequate  room  for  the  teeth,  which  con- 

1  In  the  Bulletin  Ge'ndrale  de  Thdrapeutique,  May  and  July,  1843. 


356  HYPERTROPHY   OF   THE   TONSILS. 

sequently  overlap  each  other  very  much,  while  at  the  same  time  the 
palate  becomes  unusually  high  and  arched.  Nor  is  this  the  only  mode 
in  which  due  development  is  interfered  with ;  but  it  was  noticed  five- 
and-twenty  years  ago  by  Dupuytren  that  enlargement  of  the  tonsils  and 
the  pigeon-breast  very  usually  go  together.  The  fact  was  confirmed  by 
others,  but  I  believe  that  Mr.  Shaw1  was  the  first  person  to  offer  an 
explanation  of  it.  He  pointed  out  how  the  obstacle  to  the  free  entrance 
of  air  into  the  lungs  prevents  their  being  filled  at  each  inspiratory 
effort ;  so  that  a  vacuum  would  be  formed  between  them  and  the  walls 
of  the  chest,  were  it  not  that  the  pressure  of  the  external  air  on  the 
yielding  parietes  of  the  thorax  forces  them  inwards  to  occupy  the  vacant 
space  ;  and  doing  so  most  readily  where  their  resistance  is  least,  namely, 
at  the  commencement  of  the  costal  cartilages,  produces  the  well-known 
lateral  flattening  of  the  thorax,  and  prominence  of  the  sternum.  The 
little  boy  whose  case  I  have  just  mentioned  as  necessitating  the  opera- 
tion of  laryngotomy,  gave  in  his  own  person  a  striking  illustration  of 
the  correctness  of  the  explanation  which  I  have  just  given  you.  "  On 
his  admission  into  the  hospital,"  says  Mr.  Shaw,  uand  for  several 
weeks  afterwards,  it  was  observed  that  he  had  the  pigeon-breast  form  of 
chest ;  but  after  his  tonsils  were  excised,  and  his  breathing  had  been 
perfectly  free  for  some  time,  the  sternum  subsided  to  its  proper  level, 
and  the  thorax  recovered  its  natural  shape." 

Enlargement  of  the  tonsils,  then,  though  at  first  sight  it  may  appear 
a  trivial  ailment,  is  yet  one  which  you  must  by  no  means  neglect.  A 
weakly  child,  whose  tonsils  are  but  slightly  enlarged,  will  often  get 
rid  of  his  ailment  as  he  gains  health  and  strength,  or  at  puberty  will 
completely  outgrow  it.  Any  slight  attack  of  cold,  indeed,  is  apt  to  be 
followed  by  the  increase  or  the  return  of  the  enlargement ;  but  this 
may  often  be  kept  in  check  by  the  application  of  powdered  alum  once 
or  twice  a  day  to  the  tonsils,  or  by  touching  them  every  day  or  two 
with  the  solid  nitrate  of  silver.  In  no  case,  however,  in  which  the 
hypertrophy  of  the  tonsils  was  considerable,  or  of  long  standing,  have 
I  found  these  measures,  or  the  painting  the  exterior  of  the  throat  just 
above  the  angle  of  the  jaw  with  tincture  of  iodine,  of  much  service, 
and  excision  of  the  tonsils  is  then  the  only  remedy.  Whether  this  be 
had  recourse  to  at  once,  or  whether  you  will  wait  a  few  years  till  the 
child  is  older  and  better  capable  of  that  slight  amount  of  self-control 
which  is  desirable  for  the  performance  of  the  operation,  must  depend 
on  the  size  of  the  tonsils,  on  the  amount  of  inconvenience  which  they 
occasion,  and  on  the  presence  or  absence  of  any  marked  deformity  of 
the  chest.  If  after  the  tonsils  have  been  removed,  the  chest  is  long  in 
regaining  its  natural  form,  the  use  of  dumb-bells,  and  the  careful 
practice  of  gymnastic  exercises,  are  often  of  much  service  Dupuy- 
tren's  recommendation,  too,  to  stand  the  child  with  its  back,  against  a 
wall,  and  then  placing  the  hand  upon  the  most  prominent  part  of  the 
sternum,  to  press  firmly  upon  it  during  each  expiratory  effort,  remitting 
the  pressure  during  inspiration,  in  order  that  the  child  may  fill  its  chest 

1  Medical  Gazette,  Oct.  23,  1841.  See  also  his  remarks  in  the  article  Thorax,  in  the 
Cyclopaedia  of  Anatomy  and  Physiology,  p.  1039  ;  and  also  those  of  M.  Robert,  in  his 
paper  already  referred  to. 


CYNANCHE   PAROTIDEA.  357 

as  completely  as  possible,  I  have  found  to  be,  in  spite  of  its  seeming 
roughness,  extremely  valuable  as  an  additional  means  of  removing  the 
deformity  of  the  pigeon-breast. 

Inflammation  of  the  parotid  gland, — the  CynancJie  parotidea  of 
scientific  writers,  called  mumps  by  the  vulgar, — is  an  affection  met  with 
among  children  and  young  persons,  concerning  which  a  few  words  only 
need  be  said  ;  and  I  know  of  no  more  suitable  place  than  the  present 
for  introducing  them.  It  attacks  young  persons  near  the  period  of 
puberty,  especially  boys,  much  oftener,  and  with  much  greater  severity, 
than  infants,  or  children  under  seven  years  old.  Though  it  sometimes 
occurs  as  a  sporadic  affection,  it  is  more  commonly  met  with  as  an  epi- 
demic ;  and  being  likewise  propagated  by  contagion,  it  not  infrequently 
attacks  most  of  the  inmates  of  a  boarding-school,  or  of  any  other  public 
institution  in  which  large  numbers  of  the  youth  of  either  sex  are  col- 
lected together.  The  seat  of  the  disease  is  in  one  or  both  parotid 
glands  and  in  the  adjoining  cellular  tissue ;  but  if  the  attack  be  at  all 
severe,  the  submaxillary  and  other  salivary  glands  generally  become 
involved  during  its  progress.  It  generally  sets  in  with  the  ordinary 
symptoms  of  slight  fever  or  catarrh,  which  are  followed  in  about 
twenty-four  hours  by  stiffness  of  the  neck  and  pain  about  the  lower 
jaw,  any  movement  of  which,  either  for  the  purpose  of  speaking  or  of 
mastication,  is  obviously  attended  with  considerable  suffering.  At  the 
same  time,  too,  a  swelling  makes  its  appearance  about  the  angle  of  the 
lower  jaw,  sometimes  on  one  side  only,  and  at  other  times  on  both;  and 
this  swelling  increasing  rapidly  in  size,  occasions  great  disfigurement 
of  the  face.  The  swelling  is  usually  very  tense,  but  the  colour  of  the 
skin  is  in  general  unaltered,  except  in  some  cases,  in  which  the  glands 
on  both  sides,  being  swollen,  and  pressing  much  upon  the  veins,  the 
return  of  blood  from  the  head  is  impeded,  and  the  face  assumes  a 
flushed  appearance.  If  the  swelling  be  very  considerable,  deglutition 
for  a  short  time  is  rendered  so  difficult  as  to  be  almost  impossible,  and 
the  tongue  becomes  dry  from  the  child  breathing  with  its  mouth  open  ; 
but  the  secretion  of  saliva  is  neither  morbidly  increased  or  diminished. 
If  the  disease  be  severe,  the  child  suffers  much,  is  very  feverish,  and 
may  even  be  light-headed ;  but  in  the  course  of  forty-eight  hours  from 
the  appearance  of  the  swelling  it  reaches  its  height,  and  the  fever 
begins  to  subside  and  the  swelling  to  diminish.  The  time  of  the  final 
disappearance  of  the  swelling  is  very  variable,  being  five  or  six  days  in 
some  cases,  ten  days  or  a  fortnight  in  others  ;  while  in  some  instances 
the  glands  on  one  side  are  affected  first,  and  when  the  attack  is  subsi- 
ding there,  those  of  the  opposite  side  become  affected  in  a  similar  way, 
and  the  duration  of  the  ailment  is  thus  protracted.  The  occurrence  of 
suppuration  in  the  neighbourhood  of  the  gland  is  a  rare  termination  of 
the  inflammation ;  but  is,  1  believe,  oftener  met  with  in  infants  and 
young  children  than  in  those  who  are  approaching  the  period  of  puberty. 
On  the  other  hand,  metastasis  of  the  disease  from  the  parotid  to 
the  mamma,  the  testicle,  or  tli£  brain,  of  all  of  which  instances  are 
recorded  by  different  writers,  appears  to  be  rare  in  proportion  to  the 
tender  age  of  the  patient.  The  most  formidable  of  these  metastases, 
indeed — that  to  the  brain,  would  seem  to  be  an  accident  very  seldom 


358  DISEASES   OF   THE   STOMACH. 

met  with  ;  and  neither  of  it,  nor  of  the  translation  of  the  disease  to  the 
mamma  or  the  testicle,  can  I  say  any  thing  from  personal  experience. 

The  treatment  of  this  affection  is  in  general  very  simple,  and  requires 
the  judicious  selection  of  precautionary  measures  rather  than  active 
interference.  Mild  antiphlogistic  medicines,  with  the  application  of 
warmth  locally,  are  all  that  is  usually  needed ;  and  local  depletion  is 
neither  necessary  nor  useful.  The  period  during  which  much  distress 
and  much  difficulty  of  deglutition  exist  is  generally  very  short ;  so  that 
even  in  severe  cases  it  will  be  our  wisest  course  to  await  the  sponta- 
neous subsidence  of  the  swelling.  If  suppuration  should  take  place  in 
the  cellular  tissue  about  the  gland,  a  warm  poultice  must  be  substituted 
for  the  fomentations  previously  employed.  Even  when  the  gland 
remains  enlarged,  as  it  sometimes  does  for  some  time  after  the  subsi- 
dence of  the  febrile  symptoms,  it  is  yet  in  general  the  best  plan  to  let 
it  alone,  since  the  swelling  is  sure  eventually  to  disappear  of  its  own 
accord. 

With  reference  to  the  management  of  the  metastases  of  the  disease, 
I  have  no  observations  to  make,  further  than  that  inflammation  of  the 
brain,  however  induced,  is  not  an  affection  with  which  we  can  safely 
temporize;  while  a  mild  and  palliative  treatment  will  generally  answer 
every  purpose,  when  either  the  mamma  or  the  testicle  has  become  the 
seat  of  the  affection. 


LECTURE    XXX. 

Diseases  of  the  Stomach. — Vomiting  often  symptomatic  of  disease  elsewhere — occa- 
sionally occurs  suddenly  in  a  previously  healthy  infant  without  signs  of  general  illness 
its  treatment — is  often  one  out  of  many  symptoms  of  indigestion. — Infantile  dyspepsia 
— sometimes  connected  with  general  debility  of  the  system ;  at  others,  dependent  on 
special  disorder  of  the  stomach — its  symptoms  and  treatment. 

Softening  of  the  Stomach — discovered  after  death  in  various  degrees — different  theo- 
ries as  to  its  nature — great  frequency  in  early  infancy — J)r.  Elsasser's  explanation  of 
this  fact — probably  not  correct  to  the  full  extent. 

H^matemesis  and  Meljena — very  rare — sometimes  connected  with  injury  to  the  child 
during  labour  —  its  occurrence  often  difficult  of  explanation  —  illustrative  cases. — 
Spurious  hsematemesis. 

The  diseases  to  which  the  stomach  is  liable  in  early  life  are  neither 
numerous  nor  important,  although  its  functions  are  more  or  less 
disordered  in  the  course  of  most  of  the  affections  of  childhood. 
Vomiting,  indeed,  is  more  frequent  in  the  infant  than  in  the  adult, 
and  this  not  merely  because  the  delicate  structure  of  the  organ  renders 
its  irritability  greater,  but  because  the  form  of  the  viscus,  and  its 
position  in  the  abdomen  during  early  life,  are  such  as  greatly  to 
facilitate  the  discharge  of  its  contents.  Even  when  the  first  few  months 
of  existence  kave  been  passed,  vomiting  is  still  an  occurrence  often  met 
with.  It  is  sometimes  one  of  the  first  symptoms  of  inflammation  of  the 
lungs  or  pleura  :  it  frequently  ushers  in  the  eruptive  fevers,  and  marks 
the   early   stages    of    cerebral  disease.     Causes    more    purely    local 


VOMITING   IN   EARLY   INFANCY.  359 

produce  a  similar  effect,  and  vomiting  often  attends  upon  infantile 
diarrhoea,  and  is  associated  with  signs  of  intestinal  disorder,  especially 
when  such  disorder  has  been  excited  by  improper  food.  But  besides 
these  cases,  in  which  the  disorder  of  the  stomach  is  either  the  result  of 
disease  seated  elsewhere,  or  in  which  the  disturbance  of  its  function  is 
sufficiently  explained  by  the  nature  of  the  ingesta,  instances  are  some- 
times observed  in  which  the  stomach  becomes  so  irritable  as  almost 
always  to  reject  its  contents,  or  in  which,  though  the  food  taken  be  not 
brought  up  again,  yet  the  organ  is  unable  to  effect  its  digestion. 

It  sometimes  happens  that  young  infants  are  suddenly  seized  with 
vomiting,  which,  though  violent,  and  frequently  repeated,  is  attended 
with  few  or  no  indications  of  general  intestinal  disorder.  The  child  in 
such  cases  seems  still  anxious  for  the  breast ;  but  so  great  is  the 
irritability  of  the  stomach,  that  the  milk  is  either  thrown  up  unchanged, 
immediately  after  it  has  been  swallowed,  or  it  is  retained  only  for  a 
very  few  minutes,  and  is  then  rejected  in  a  curdled  state;  while  each 
application  of  the  child  to  the  breast  is  followed  by  the  same  result. 
It  will  generally  be  found,  when  this  accident  takes  place  in  the 
previously  healthy  child  of  a  healthy  mother,  that  it  has  been  occa- 
sioned by  some  act  of  indiscretion  on  the  part  of  its  mother  or  nurse. 
She  perhaps  has  been  absent  from  her  nursling  longer  than  usual,  and, 
returning  tired  from  a  long  walk,  or  from  some  fatiguing  occupation, 
has  at  once  offered  it  the  breast,  and  allowed  it  to  suck  abundantly ;  or 
the  infant  has  been  roused  from  sleep  before  its  customary  hour,  or  it 
has  been  over-excited  or  over-wearied  at  play,  or,  in  hot  weather,  has 
been  carried  about  in  the  sun  without  proper  protection  from  its  rays. 

The  infant^n  whom,  from  any  of  these  causes,  vomiting  has  come  on, 
must  at  once  be  taken  from  the  breast,  and,  for  a  couple  of  hours, 
neither  food  nor  medicine  should  be  given  to  it.  It  may  then  be  offered 
a  teaspoonful  of  cold  water  ;  and,  should  the  stomach  retain  this,  one 
or  two  more  spoonfuls  may  be  given  in  the  course  of  the  next  half 
hour.  If  this  be  not  rejected,  a  little  isinglass  may  be  dissolved  in  the 
water,  which  must  still  be  given  by  a  teaspoonful  at  a  time,  frequently 
repeated  ;  or  cold  barley-water  may  be  given  in  the  same  manner.  In 
eight  or  ten  hours,  if  no  return  of  vomiting  take  place,  the  experiment 
may  be  tried  of  giving  the  child  its  mother's  milk,  or  cow's  milk  diluted 
with  water,  in  small  quantities,  and  from  a  teaspoon.  If  the  food 
thus  given  do  not  occasion  sickness,  the  infant  may  in  from  twelve  to 
twenty-four  hours  be  restored  to  the  breast ;  with  the  precaution,  how- 
ever, of  allowing  it  to  suck  only  very  small  quantities  at  a  time,  lest, 
the  stomach  being  overloaded,  the  vomiting  should  again  be  produced. 

In  many  instances  where  the  sickness  has  arisen  from  some  accidental 
cause,  such  as  those  above  referred  to,  the  adoption  of  these  precautions 
will  suffice  to  restore  the  child  to  health.  If,  however,  other  indications 
of  gastric  or  intestinal  disorder  have  preceded  the  sickness,  or  be  asso- 
ciated with  it,  medicine  cannot  be  wholly  dispensed  with.  According  to 
the  age  of  the  child,  a  quarter,  half,  or  a  whole  grain  of  calomel  may 
be  laid  upon  the  tongue,  while  sucking  is  forbidden,  and  the  plan 
already  recommended  is  in  other  respects  strictly  carried  out.  If  the 
vomiting  have  already  continued  for  several  hours  before  the  adoption 


360  INFANTILE   DYSPEPSIA. 

of  any  treatment,  a  small  mustard  poultice  may  likewise  be  applied  to 
the  epigastrium.  In  about  a  couple  of  hours  after  the  calomel  has 
been  given,  the  child  may  have  a  teaspoonful  of  a  mixture  containing 
small  doses  of  the  bicarbonate  of  potash  and  of  hydrocyanic  acid  ;  and 
this  may  be  continued  every  three  or  four  hours  so  long  as  any  unu- 
sual irritability  of  the  stomach  remains. 

Sickness,  however,  is  not  always  a  solitary  symptom,  unattended  with 
other  indications  of  gastric  disorder,  but  it  is  sometimes  associated  with 
the  signs  of  general  impairment  of  the  digestive  powers.  In  its  graver 
forms,  indigestion  is  associated  with  greatly  impaired  nutrition,  and 
with  all  those  serious  results  which  are  characteristic  of  the  atrophy  of 
young  children.  But  it  sometimes  happens  that,  though  the  child  does 
not  lose  much  flesh,  yet  digestion  is  ill  performed,  and  various  dyspeptic 
symptoms  appear,  which  would  be  troublesome  rather  than  alarming, 
if  it  were  not  that  they  are  often  connected  with  the  strumous  dia- 
thesis, and  are  the  first  indications  of  a  state  of  constitution  in  which, 
after  the  lapse  of  a  few  months,  pulmonary  phthisis  is  very  apt  to 
supervene. 

In  some  of  these  cases  there  is  complete  anorexia,  the  infant  caring 
neither  for  the  breast  nor  for  any  other  food  that  may  be  offered  it.  It 
loses  the  look  of  health,  and  grows  pale  and  languid,  although  it  may 
not  have  any  especial  disorder  either  of  the  stomach  or  bowels.  It 
sucks  but  seldom,  and  is  soon  satisfied ;  and  even  of  the  small  quantity 
taken,  a  portion  is  often  regurgitated  almost  immediately.  This  state 
of  things  is  sometimes  brought  on  by  a  mother's  over-anxious  care, 
wTho,  fearful  of  her  infant  taking  cold,  keeps  it  in  a  room  too  hot  or 
too  imperfectly  ventilated.  It  follows  also,  in  delicate  infants,  on 
attacks  of  catarrh  or  diarrhoea,  but  is  then  for  the  most  part  a  passing 
evil,  which  time  will  cure.  In  the  majority  of  cases,  however,  the  loss 
of  appetite  is  associated  with  evidence  of  the  stomach's  inability  to 
digest  even  the  small  quantity  of  food  taken,  and  there  exists  more  or 
less  marked  gastric  or  intestinal  disorder.  Anorexia,  too,  is  far  from 
being  a  constant  attendant  upon  infantile  dyspepsia ;  but  in  still  more 
numerous  instances,  although  the  power  of  assimilating  the  food  is  in 
a  great  measure  lost,  yet  there  is  an  unnatural  craving  for  it,  and  the 
infant  never  seems  so  comfortable  as  when  sucking.  But  though  it 
sucks  much,  the  milk  evidently  does  not  sit  well  upon  the  stomach ;  for 
soon  after  sucking,  the  child  begins  to  cry,  and  appears  to  be  in  much 
pain  until  it  has  vomited.  The  milk  thrown  up  is  curdled,  and  its 
rejection  is  followed  by  immediate  relief,  but  at  the  same  time  by  the 
desire  for  more  food,  and  the  child  can  often  be  pacified  only  by  allow- 
ing it  to  suck  again.  In  other  cases,  vomiting  is  of  much  less  frequent 
occurrence,  and  there  is  neither  a  craving  desire  for  food,  nor  much 
pain  after  sucking,  but  the  infant  is  distressed  by  frequent  acid  or 
offensive  eructations :  its  breath  has  a  sour  or  nauseous  smell,  and  its 
evacuations  have  a  most  foetid  odour.  The  condition  of  the  bowels 
that  exists  in  connection  with  these  different  forms  of  dyspepsia  is 
variable.  In  cases  of  simple  anorexia,  the  debility  of  the  stomach  is 
participated  in  by  the  intestines ;  their  peristaltic  action  is  feeble,  and 
constipation  is  of  frequent  occurrence,  though  the  evacuations  do  not 


TREATMENT   OF   DYSPEPSIA  FROM   DEBILITY.  361 

always  present  any  marked  deviation  from  their  character  in  health. 
Constipation,  however,  though  a  frequent,  is  not  an  invariable  atten- 
dant on  indigestion,  but  the  bowels  in  some  cases  act  with  due 
regularity.  If  the  infant  be  brought  up  entirely  at  the  breast,  the 
evacuations  are  usually  liquid,  of  a  very  pale  yellow  colour,  often 
extremely  offensive,  and  contain  shreds  of  curdled  milk,  which,  having 
escaped  through  the  pylorus,  pass  unchanged  along  the  whole  tract  of 
the  intestines.  In  many  instances,  however,  the  infant  having  been 
observed  not  to  thrive  at  the  breast,  arrow-root  or  other  farinaceous 
food  is  given  to  it,  which  the  digestive  powers  are  quite  unable  to  assi- 
milate, and  which  gives  to  the  motions  the  appearance  of  putty  or  pipe- 
clay, besmeared  more  or  less  abundantly  with  intestinal  mucus.  The 
evacuations  are  often  party-coloured,  and  sometimes  one  or  two 
unhealthy  motions  are  followed  by  others  which  appear  perfectly  natu- 
ral; while  attacks  of  diarrhoea  often  come  on,  and  the  matters 
discharged  are  then  watery,  of  a  dark,  dirty  green  colour,  and  exceed- 
ingly offensive  odour. 

Dyspeptic  infants,  like  dyspeptic  adults,  often  continue  to  keep  up 
their  flesh  much  better  than  could  be  expected,  and  in  many  cases  even- 
tually grow  up  to  be  strong  and  healthy  children.  Still,  the  condition 
is  one  that  not  merely  entails  considerable  suffering  upon  the  child, 
but,  by  its  continuance,  seriously  impairs  the  health,  renders  the  child 
but  little  able  to  bear  up  against  any  intercurrent  disease,  and  develops 
the  seeds  of  latent  phthisis. 

Within  the  space  that  can  be  allotted  to  each  subject  in  these 
lectures,  it  is  not  possible  to  do  more  than  just  glance  at  some  of  the 
main  points  to\be  borne  in  mind  in  the  treatment  of  infantile  dyspepsia. 
Those  cases,  the  chief  symptom  of  which  consists  in  the  loss  of  appetite, 
usually  require,  and  are  much  benefited  by,  a  generally  tonic  plan  of 
treatment.  All  causes  unfavourable  to  health  must  be  examined  into, 
and,  as  far  as  possible,  removed.  It  must  be  seen  that  the  nursery  is 
well  ventilated,  and  that  its  temperature  is  not  too  high ;  while  it  will 
be  found  that  no  remedy  is  half  so  efficacious  as  change  of  air.  Next, 
it  must  not  be  forgotten  that  the  regurgitation  of  the  food  is  due  in 
a  great  measure  to  the  weakness  and  consequent  irritability  of  the 
stomach ;  and  care  must  therefore  be  taken  not  to  overload  it.  If 
these  two  points  be  attended  to,  benefit  may  then  be  looked  for  from 
the  administration  of  tonics.  These  tonics  may  either  be  such  as  the 
infusion  of  orange-peel  with  a  few  drops  of  sulphuric  acid  and  of  some 
tincture  ;*  or  should  any  disposition  to  diarrhoea  have  appeared,  the 

(No.  22.) 
1  R  Acid-  Sulph.  dil.  TT^xvj. 
Tinct.  Aurantii  Co.  gj. 
Syrupi,  £j. 
Inf.  Aurantii,  ^j. 

Aq.  Cinnamomi,  gij.     M.     3J.  ter  die. 
For  a  child  a  year  old. 

extract  with  the  compound  tincture  of  bark  will  be  preferable  f  or  if 
2  See  Formula  No.  3,  p.  45. 


362  TREATMENT   OP   DYSPEPSIA   PROM   GASTRIC   DISORDER. 

the  stomach  be  very  irritable,  the  liquor  cinchonse  in  combination  with 
small  doses  of  hydrocyanic  acid1  may  be  given  with  advantage,  when 
any  other  medicine  would  be  rejected.  As  the  general  health  improves, 
the  constipated  condition  of  the  bowels  so  usual  in  these  cases  will  by 
degrees  disappear.  Even  if  the  symptoms  should  call  for  medical  inter- 
ference, it  is  not  by  drastic  purgatives  that  its  cure  must  be  attempted. 
A  soap  suppository  will  sometimes  excite  the  bowels  to  daily  action ;  or 
friction  of  the  abdomen  twice  a  day  with  warm  oil,  or  with  a  liniment 
composed  of  one  part  of  Linimentum  Saponis,  one  of  olive  oil,  and  two 
of  tincture  of  aloes,  will  sometimes  have  the  same  effect.  Should  it 
become  necessary  to  give  aperients  internally,  the  decoction  of  aloes 
sweetened  with  liquorice,  and  mixed  with  caraway  or  aniseed  water, 
generally  answers  the  purpose  very  well  ;2  while  the  employment  of 

(No.  23.) 
2  R  Decoct.  Aloes  Co.  gvj. 
Extr.  Glycyrrhizee,  ^j. 
Aquse  Anisi,  spj.     M.     gj.  vel.  gij.  p.  r.  n. 
For  a  child  a  year  old. 

mercurials  must  be  restricted  to  cases  in  which  there  is  very  evident , 
deficiency  in  the  biliary  secretion. 

A  different  plan  must  be  adopted  in  those  forms  of  indigestion  which 
depend  on  some  cause  other  than  mere  debility  of  the  system.  The 
rule,  indeed,  which  limits  the  quantity  of  food  to  be  taken  at  one  time 
is  no  less  applicable  here,  for  the  rejection  of  the  curdled  milk  may  be 
the  result  of  nothing  more  than  of  an  effort  which  nature  makes  to  reduce 
the  work  that  the  stomach  has  to  do  within  the  powers  of  that  organ. 
But  when,  notwithstanding  that  due  attention  is  paid  to  this  important 
point,  uneasiness  is  always  produced  by  taking  food,  and  is  not  relieved 
till  after  the  lapse  of  twenty  minutes  or  half  an  hour,  when  vomiting 
takes  place,  or  when  the  infant  suffers  much  from  flatulence  and  from 
frequent  acid  or  nauseous  eructations,  it  is  clear  that  the  symptoms  are 
due  to  something  more  than  the  mere  feebleness  of  the  system. 

It  is  not,  however,  in  these  cases  the  mere  fact  of  the  infant  vomiting 
its  food,  or  of  the  milk  so  vomited  being  rejected  in  a  coagulated  state, 
which  indicates  the  stomach  to  be  disordered,  but  it  is  the  circumstance 
of  firmly-coagulated  milk  being  rejected  with  much  pain,  and  after  the 
lapse  of  a  considerable  interval  from  the  time  of  taking  food,  which 
warrants  this  conclusion.3  The  coagulation  of  its  case  in  is  the  first 
change  which  the  milk  of  any  animal  undergoes  when  introduced  into 
the  stomach,  though  the  coagulum  formed  by  human  milk  is  soft,  floc- 
culent,  and  not  so  thoroughly  separated  from  the  other  elements  of  the 
fluid  as  the  firm  hard  curd  of  cow's  milk  is  from  the  whey  in  which  it 
floats.  In  a  state  of  health,  the  abundantly  secreted  gastric  juice 
speedily  re-dissolves  the  chief  part  of  the  casein,  while  the  subsequent 

1  See  Formula  No.  20,  p.  277. 

3  The  physiology  and  chemistry  of  the  digestion  of  the  milk  -will  be  found  fully  treated 
in  the  article  Milch,  in  Wagner's  Handworterbuch  der  Physiologie  ;  and  in  ElsJisser's 
essay,  Ueber  die  Magenerweichung  der  Stiuglinge,  8vo.  Stuttgart,  1846.  They  arc  the 
authorities  for  the  statements  in  the  text. 


DIET   OF   DYSPEPTIC   INFANTS.  363 

addition  to  it  of  the  alkaline  bile  converts  it  into  an  albuminate  of  soda  ; 
and  being  thus  assimilated  as  nearly  as  possible  to  the  characters  of 
one  of  the  chief  elements  of  the  blood,  it  is  easily  absorbed  by  the 
lacteals,  and  passes  into  the  mass  of  the  circulating  fluid. 

Milk  tends,  however,  to  undergo  changes  spontaneously,  which 
produce  its  coagulation,  and  the  occurrence  of  these  changes  is  greatly 
favoured  by  a  moderately  high  temperature,  such  as  that  which  exists 
in  the  stomach.  But  the  alterations  in  the  fluid  which  attend  upon 
this  spontaneous  coagulation  are  very  different  from  those  which  are 
brought  about  in  it  by  the  vital  processes  of  digestion.  A  free  acid 
becomes  developed  abundantly  within  it,  and  the  acid  thus  generated 
shews  none  of  the  solvent  power  of  gastric  juice,  but  by  its  presence 
impedes  rather  than  favours,  digestion.  Every  nurse  is  aware  that  a 
very  slight  acidity  of  the  milk  with  which  the  infant  is  fed  will 
suffice  to  occasion  vomiting,  stomach-ache,  and  diarrhoea;  and  the 
result,  as  far  as  the  child  is  concerned,  must  be  much  the  same  whether 
the  acetous  fermentation  had  begun  in  the  milk  before  it  was  swallowed, 
or  whether  it  commences  afterwards,  in  consequence  of  the  disordered 
condition  of  the  stomach,  and  the  absence  of  a  healthy  secretion  of 
gastric  juice. 

The  nature  of  the  food  is  the  first  point  that  requires  attention  in 
the  management  of  these  cases  of  infantile  dyspepsia.  If  the  child 
had  been  fed  on  cow's  milk,  the  symptoms  may  have  been  produced  by 
the  gastric  juice  being  unable  to  re-dissolve  the  hard  curd  formed  by 
the  coagulation  of  its  casein.  In  this  case  the  infant  may  sometimes 
be  restored  to  health  without  the  employment  of  any  medicine,  by 
diluting  the  rn^lk,  by  substituting  asses'  milk,  or  even  by  giving  whey 
for  a  day  or  two,  until  the  stomach  recovers  its  powers  of  digesting 
casein.  The  addition  of  a  small  quantity  of  some  alkali — as  the 
carbonate  of  potash,  or  prepared  chalk — to  the  milk,  is  another  precau- 
tion which  should  not  be  omitted,  since  while  it  does  not  at  all  interfere 
with  digestion,  it  tends  to  prevent  the  matters  taken  into  the  stomach 
so  readily  undergoing  the  acetous  fermentation.  The  indiscriminate 
employment  of  alkalies  as  medicine,  is,  however,  not  to  be  recom- 
mended;— they  are  of  service  combined  either  with  minute  doses  of 
hydrocyanic  acid,  or  of  laudanum,  when  the  irritability  of  the  stomach 
is  extreme,  as  in  those  cases  which  we  referred  to  at  the  commencement 
of  this  lecture  ; — they  are  also  useful  in  cases  of  a  more  chronic  kind, 
where  the  sour  smell  of  the  evacuations,  and  the  frequent  occurrence 
of  acid  eructations,  indicate  the  presence  of  an  excess  of  acid  in  the 
primse  vise.  I  do  not  give  them  by  themselves,  but  in  combination 
with  some  tonic,  as  the  infusion  of  calumba,  to  which  the  extract  of 
dandelion  and  the  tincture  of  rhubarb  may  be  added  if  as  some- 
times happens,1  the  functions  of  the  liver  appear  to  be  but  ill  performed. 

(No.  24.) 
1  R  Sodae  Sesquicarb.  gr.  xxiv. 
Extr.  Taraxaci,  ^ij. 
Tinct.  Rhei,  3J. 
Inf.  Calumbse,  3XJ. 
Aquoe  Carui,  giv.     M.     31J.  bis  die. 
For  a  child  a  year  old 


361  TREATMENT   Off   INFANTILE   DYSPEPSIA. 

Vomiting  of  the  milk  in  a  coagulated  state  is  no  proof  of  the  presence 
of  an  excess  of  acid  in  the  stomach.  It  may  indicate  a  condition  in 
which  the  secretion  of  the  gastric  juice  is  either  disordered  or 
insufficient,  and  in  which  the  acetous  fermentation  is  set  up  in  the 
contents  of  the  stomach,  because  the  organ  is  inadequate  to  the  proper 
discharge  of  those  vital  functions  which  would  prevent  its  occurrence. 
Such  cases,  and  they  are  many — and  among  them  may  be  classed  all 
those  in  which  the  breath  is  offensive  and  the  infant  is  distressed  by 
nauseous  eructations — are  benefitted  by  the  mineral  acids  in  combi- 
nation with  some  bitter  infusion ;  as  for  instance,  the  infusion  of 
cascarilla  with  hydrochloric  acid.1  I  have  often  observed  the  action  of 
the  bowels  become  regular  and  the  appearance  of  the  evacuations 
healthy,  during  its  administration.  The  use  of  mercurials,  indeed,  so 
generally  resorted  to  in  order  to  correct  some  real  or  fancied  disorder 
of  the  liver,  has  become  too  indiscriminate  a  practice.  The  diarrhoea, 
with  very  pale  light  yellow  evacuations,  that  comes  on  in  some  of  these 
cases,  is  often  arrested  by  a  spare  diet  and  by  the  administration  of 
very  small  doses  of  sulphate  of  magnesia  and  tincture  of  rhubarb ; 
such  as  five  grains  of  the  former  and  ten  minims  of  the  latter  three 
times  a  day  to  a  child  a  year  old.3     In  cases  where  diarrhoea  has  been 

(No.  25.)  (No.   26.) 

!  R  Acid.  Hydrochlor.  dil.  TTLxvj.  2  R  Magnesise  Sulphatis,  33. 

Syr.  Aurantii,  3J.  Tinct.  Rhei,  gj. 

Tinct.  Aurantii,  3J.  Syr.  Zinziberis,  spj. 

Inf.  Cascarilloe,  £x.     M.     gj.  ter  die.  Aquae  Carui,  gix.     M.-    ^j.  ter  die. 

For  children  a  year  old. 

long  continued,  or  where  the  evacuations  are  very  white,  and  resemble 
putty,  mercurials  are  generally  needed ;  as  they  are,  also,  in  those  cases 
where  the  horribly  offensive  odour  of  the  evacuations  proves  that  the 
contents  of  the  intestines  have  been  undergoing  a  process  akin  to 
putrefaction.  The  mercury  and  chalk  powder  in  small  doses  night  and 
morning,  is  the  mildest  preparation  that  can  be  given.  Sometimes, 
however,  it  causes  nausea  or  vomiting,  and  very  small  doses  of  calomel 
must  then  be  substituted  for  it ;  while,  if  the  mercurial  should  excite 
the  bowels  to  over-action,  this  tendency  may  generally  be  checked  by 
combining  it  with  Dover's  powder. 

The  same  rules  must  guide  us  in  the  management  of  children  whom, 
though  they  be  still  at  the  breast,  the  symptoms  of  dyspepsia  make 
their  appearance.  Disorder  of  the  digestive  function  is,  however,  much 
less  common  before  weaning  than  afterwards.  It  may  depend  on  the 
mother's  milk  being  from  some  cause  or  other  ill  adapted  to  the  support 
of  tbe  child;  and  hence  the  condition  of  the  parent's  health  must  in  all 
these  cases  engage  our  attention. 

With  these  general  rules  I  must  dismiss  the  subject  of  indigestion, 
content  to  have  pointed  out  the  principles  that  should  guide  you.  It 
must  be  left  to  your  own  experience  in  future  years  to  supply  the 
details.  I  have  touched  on  the  subject,  too,  only  with  reference  to  the 
infant,  for  as  the  child  grows  older  and  its  food  becomes  the  same  as 


SOFTENING   OF  THE   STOMACH.  365 

that  of  the  adult,  the  symptoms  of  disorder  of  its  digestive  organs 
become  the  same  too,  and  require  a  similar  treatment. 

In  many  works  on  the  diseases  of  childhood  we  meet  with  an  enume- 
ration of  rather  obscure  symptoms,  which  are  stated  to  indicate  the 
existence  of  gastritis  or  gastro-enteritis,  and  to  be  followed  by  more  or 
less  considerable  softening  of  the  stomach  or  intestines,  or  of  both.  A 
similar  condition  of  the  stomach  was  observed  by  John  Hunter  in  the 
adult,  and  was  conceived  by  him  to  be  the  result  of  the  action  of  the 
gastric  juice  upon  the  tissues  after  death.  The  carefully  conducted 
experiments  of  Dr.  Carswell  have  completely  confirmed  the  opinion  of 
Mr.  Hunter  with  reference  to  the  agent  by  which  this  softening  is 
effected;  while  they  have  further  shown  that  it  is  independent  of  the 
person's  previous  health.  Some  writers,  among  whom  may  be  men- 
tioned those  eminent  authorities  M.  Cruveilhier  and  Professor  Roki- 
tansky,  have,  however,  dissented  in  a  measure  from  these  views,  and 
have  endeavoured  to  distinguish  between  two  kinds  of  softening,  one  of 
which  they  regard  as  a  post-mortem  occurrence ;  the  other,  which  is  that 
chiefly  observed  in  infancy,  they  consider  to  be  the  result  of  disease. 

Softening  of  the  stomach  varies  in  degree  from  a  slight  diminution 
in  the  consistence  of  the  mucous  membrane,  to  a  state  of  complete 
diffluence  of  all  the  tissues  of  the  organ,  in  which  it  breaks  down  under 
the  finger  on  the  slightest  touch,  or  even  gives  way  of  its  own  accord, 
and  allows  of  the  escape  of  its  contents  into  the  abdomen.  When  the 
change  is  not  far  advanced,  the  exterior  of  the  stomach  presents  a  per- 
fectly natural  appearance,  but  on  laying  it  open,  a  colourless,  or  slightly 
brownish,  tenacious  mucus,  like  the  mucilage  of  quince  seeds,  is  found 
closely  adhering  to  its  interior,  over  a  more  or  less  considerable  space 
at  the  great  end  of  the  organ,  and  extending  along  the  edges  of  its 
rugae.  This  mucus  is  easily  washed  away,  and  the  muscular  coat  of 
the  stomach  in  those  parts  to  which  it  had  adhered  is  then  left  almost 
or  altogether  bare,  and  denuded  of  its  mucous  membrane.  When  the 
change  has  gone  further,  the  stomach  at  its  great  end  presents  a  semi- 
transparent  appearance,  though  not  uniformly  so,  but  in  streaks  running 
in  the  direction  of  the  rugae ;  the  destruction  of  the  tissues  having  in 
those  situations  reached  deeper  than  elsewhere,  and  involved  a  portion 
of  the  muscular  as  well  as  the  mucous  coat  of  the  organ.  If  roughly 
handled,  the  stomach  in  many  cases  gives  way,  an  irregular  rent  taking 
place  at  its  great  end,  where  the  coats  of  the  organ  are  found  to  be  soft 
and  pulpy,  and  to  breaK  down  easily  under  the  finger.  In  the  next 
degree,  the  coats  of  the  stomach  are  found  to  have  been  already  dis- 
solved in  some  parts,  so  that  the  contents  of  the  organ  have  escaped 
into  the  abdominal  cavity.  The  whole  of.  the  great  end  of  the  stomach, 
and  a  considerable  extent  of  the  posterior  wall,  are  now  reduced  to  a 
gelatinous  condition,  in  which  no  distinction  of  tissues  is  apparent ;  and 
the  parts  thus  altered  are  either  transparent  and  colourless,  or  else  of 
a  pale,  rose-red,  hue.  The  interior  of  the  organ  sometimes  presents  a 
similar  tinge,  even  beyond  the  limits  to  which  the  softening  of  its  tissue 
has  extended.  This,  however,  is  by  no  means  constantly  observed,  while 
in  no  case  is  there  any  injection  of  the  vessels  of  the  stomach,  or  any 
evidence  of  its  having  been  the  seat  of  real  inflammatory  action.     The 


366  SOFTENING   OF   THE    STOMACH   AND   INTESTINES. 

opaque  and  brownish  appearance  of  the  tissues — characteristic  of  pulpy 
softening — is  but  seldom  met  with  in  infancy. 

Softening  of  the  intestines,  though  much  less  frequent  than  softening 
of  the  stomach,  is  observed  under  similar  circumstances,  and  presents 
much  the  same  characters.  The  exterior  of  the  intestines  is  generally 
anaemic,  and  the  softened  parts  present  no  trace  of  increased  vascularity, 
but  are  either  colourless,  or  of  a  pale  rose  hue.  The  mucous  membrane 
in  their  interior  is  neither  ulcerated  nor  abraded,  but  is  found  in  some 
parts  to  be  much  softened,  or  even  altogether  absent  in  small  patches. 
The  muscular  coat,  too,  is  sometimes  destroyed,  though  no  abrupt  edge 
marks  the  limits  of  its  destruction,  but  there  is  a  gradual  attenuation 
of  the  tissue  down  to  the  spot  where  the  peritoneum  is  laid  completely 
bare.  Several  of  these  softened  patches  are  generally  met  with  in  the 
same  subject,  and  at  some  of  them  the  bowel  is  often  found  to  have 
given  way,  or  it  breaks  down  in  the  attempt  to  lay  open  its  cavity. 

The  allegation,  that  softening  of  the  stomach  in  the  adult  occurs  with 
greater  frequency  in  persons  who  have  died  from  some  diseases,1  than 
in  those  who  have  died  from  others,  has  led  to  the  hypothesis  that,  in 
the  former  case,  a  diseased  and  superabundant  secretion  of  gastric  juice 
during  the  life  of  the  individual  had  caused  the  softening  of  his  stomach 
after  death.  The  same  hypothesis  has  been  applied  to  account  for  its 
peculiar  frequency  in  infancy,  since  at  no  period  of  life  is  gastric  dis- 
order so  common  as  then.  Some  writers  have  advanced  still  further, 
and  have  endeavoured  to  connect  the  existence  of  a  softened  state  of 
the  stomach  after  death,  with  certain  well-marked  symptoms  of  disorder 
of  its  functions ;  for  my  own  part,  however,  I  have  not  been  able  to 
discover  any  peculiarity  in  the  character  of  such  symptoms,  nor  even 
any  constancy  in  their  occurrence. 

The  much  greater  frequency  of  softening  of  the  stomach  and  intes- 
tines in  infancy  and  early  childhood  than  in  adult  age,  and  the  greater 
amount  and  wider  extent  of  the  alterations,  have  received  considerable 
elucidation  from  the  recent  researches  of  Dr.  Elsasser.2  He  found  that 
a  much  more  rapid  action  upon  animal  tissues  than  that  exerted  by  the 
gastric  juice,  was  put  forth  by  any  substance  capable  of  undergoing  the 
acetous  fermentation,  combined  with  pepsin.  Such  substances  are  fur- 
nished by  the  milk  as  well  as  by  the  various  farinaceous  and  saccharine 
matters  on  which  infants  almost  exclusively  subsist.  The  tendency  of 
these  substances  to  undergo  the  acetous  fermentation  is  checked  by  the 
presence  of  healthy  gastric  juice,  while,  as  we  know  by  experience,  it 
takes  place  very  readily  in  infants  who  are  dyspeptic,  and  to  a  very 
remarkable  degree  in  many  cases  of  infantile  diarrhoea.     Facts  bear  out 

1  The  recently  published  very  elaborate  work  of  MM.  Herrich  andPopp,  Der  plotzliche 
Tod  aus  inneren  (Jrsachen,  8vo.  Regensburg,  1848,  contains  at  page  330,  a  table  of  104 
cases  in  which  softening  of  the  stomach  was  found  after  death  from  different  causes,  and 
at  various  ages.  In  no  instance  were  symptoms  observed  that  would  have  enabled  any 
one  to  pronounce  beforehand  that  softening  of  the  stomach  would  be  discovered  after 
death.  In  by  far  the  greater  number  of  cases  the  stomach  was  empty,  showing  that  the 
occurrence  very  often  did  not  depend  on  digestion  going  on  at  the  time  of  death ;  while 
the  period  of  childhood,  the  rapid  course  of  the  fatal  disease,  and  death  from  cerebral 
affections,  were  the  only  circumstances  which  appeared  to  have  any  clearly  appreciable 
influence  in  favoring  its  production. 

2  Die  Magenerweichung  der  Siiuglinge,  8vo.     Stuttgart,  1846. 


OCCURS  AFTER  ITS   DEATH — THEORIES   AS   TO   ITS   CAUSE.  367 

to  a  very  great  extent  the  opinion  of  M.  Elsasser.  Out  of  104  cases  of 
softening  of  the  stomach  that  came  under  the  notice  of  two  very  emi- 
nent German  physicians,  MM.  Herrich  and  Popp,  72  were  met  with  in 
the  period  of  infancy  or  early  childhood.  My  own  notes  on  this  point, 
though  too  few  to  be  of  any  weight,  yet  point  to  a  similar  conclusion  ; 
for  of  14  cases  of  softening  of  the  stomach  or  intestines,  or  of  both,  ob- 
served out  of  a  total  of  61  cases  in  which  the  condition  of  those  viscera 
was  carefully  recorded,  11  were  met  with  in  children  under  two  years 
of  age ;  while  out  of  a  total  of  889  examinations  of  infants  under  the 
age  of  three  months  in  the  Foundling  Hospital  at  Vienna,  M.  Bednar1 
met  with  100  instances  of  softening  of  the  stomach  or  intestines ;  in  61 
of  which  death  had  taken  place  from  diarrhoea.  I  need  scarcely  add 
this  theory  of  M.  Elsasser's  is  only  supplementary  to  Mr.  Hunter's, 
and  is  perfectly  reconcilable  with  the  correctness  of  his  observations, 
and  of  those  of  Dr.  Carswell. 

Among  those  rare  diseases,  too  seldom  met  with  for  any  person  to 
have  what  can  be  called  real  experience  about  them,  may  be  mentioned 
the  vomiting  and  purging  of  blood  occasionally  observed  in  infants  and 
young  children.  In  the  greater  number  of  cases  the  occurrence  has 
taken  place  within  a  few  days2  after  birth,  sometimes  within  a  few 
hours,  and  in  some  instances  has  followed  a  tedious  or  difficult  labour, 
in  which  the  head  of  the  child  has  been  much  compressed,  or  its  abdo- 
men has  been  pressed  on,  or  otherwise  injured,  during  attempts  at  its 
extraction;  while  in  other  cases  the  difficult  establishment  of  respira- 
tion has  seemed  to  be  the  predisposing  cause  of  the  haemorrhage.  Very 
often,  however,  no  reason  can  be  assigned  for  it ;  and  the  vomiting  of 
blood,  sometimes  associated  with  its  discharge  per  anum,  has  been 
unattended  with  other  indications  of  disorder  of  the  abdominal  viscera. 
In  most  cases  the  haematemesis  has  not  recurred  above  two  or  three 
times  in  any  quantity ;  and  the  children,  though  at  first  very  much 
exhausted  by  the  loss  of  blood,  have,  in  about  half  the  cases,  eventually 
recovered.  In  a  few  instances,  however,  recovery  has  been  but  partial, 
and  the  children  have  sunk  into  a  cachectic  condition,  in  which  they 
died.  When  death  has  taken  place  from  the  immediate  effects  of  the 
haemorrhage,  the  liver  and  the  abdominal  veins  have  sometimes  been 
found  gorged  with  blood,  and  blood  has  been  found  within  the  intes- 
tines, or  extravasated  between  their  coats,  constituting  what  has  been 
termed  abdominal  apoplexy, — appearances  which  have  been  supposed 
to  indicate  that  some  impediment  to  the  establishment  of  the  new 
course  of  the  circulation  which  the  blood  should  follow  after  birth,  had 
given  rise  to  the  accident. 

1  have  nothing  to  say  about  the  treatment  of  an  accident  which  in 
general  occurs  too  causelessly  to  furnish  indications  for  its  prevention, 
and  too  suddenly  to  allow  of  the  employment  of  measures  for  its  arrest ; 
but  I  will  give  you  the  result  of  my  scanty  experience  concerning  it, 
which  amounts  to  three  cases.     In  one  of  these  cases  the  haemorrhage 

i  Die  Krankheiten  der  Neugebornen,  &c  8vo.  p.  76.     Wien,  1850. 

2  Within  6  days  in  17  ;  and  within  86  hours  in  9  out  of  20  cases  collected  by  M.  Rilliet, 
in  his  essay  Surles  He"morrhagies  Intestiniales  chez  les  Nouveau  ne"s,  published  in  Gaz. 
Med.  de  Paris,  No.  53,  1848. 


368  H^EMATEMESIS   AND   HELENA. 

occurred,  without  apparent  cause,  soon  after  birth,  and  ceased  sponta- 
neously ;  while  in  the  other  two  it  took  place  at  a  later  period,  and 
approached  in  its  characters  more  nearly  to  similar  occurrences  in 
adult  age. 

The  subject  of  the  first  observation  was  a  male  child,  who  was  born 
of  a  healthy  mother,  after  a  short  and  easy  labour,  at  11  A.  M.  on  Sept. 
23,  1845.  The  infant  was  well  grown,  and  apparently  strong  and 
healthy,  and  continued  so  till  2J  a.  m.  on  the  24th,  when,  without  any 
previous  sickness,  or  other  indications  of  illness,  he  vomited  nearly  half 
a  teacupful  of  blood.  This  vomiting  was  not  attended  with  any  pain, 
nor  was  any  large  quantity  of  blood  rejected  afterwards,  but  the  child 
continued  at  intervals  of  not  more  than  an  hour  to  throw  up  small  quan- 
tities of  dark  greenish  matter,  resembling  meconium,  and  mixed  with 
mucus ;  and  on  the  morning  of  the  25th  he  vomited  a  small  portion  of 
coagulated  blood,  as  big  as  the  top  of  the  little  finger.  Between  the 
time  of  the  child's  birth  and  the  morning  of  the  25th,  the  bowels  acted 
seven  times  ;  the  motions  were  rather  scanty,  and  consisted  entirely  of 
meconium.  The  child  sucked  well,  did  not  appear  in  distress  ;  its  sur- 
face was  warm,  and  its  abdomen  neither  full  nor  tender.  The  matters 
vomited  did  not  decompose,  although  they  were  kept  for  some  days  ; 
and  when  examined  under  the  microscope,  they  were  seen  to  be  made 
up  of  a  great  number  of  granular  globules,  with  which  were  intermixed 
some  scales  of  tesselated  epithelium. 

The  27th  of  September  was  the  last  day  on  which  the  dark  solid 
matter  like  mecomium  was  vomited ;  but  the  child  continued  to  be  sick 
occasionally  until  October  7,  although  the  attacks  of  sickness  did  not 
seem  to  be  excited  by  sucking,  but  occurred  in  general  when  the 
stomach  was  empty,  and  ended  with  the  rejection  of  a  small  quantity 
of  mucus,  occasionally  of  a  greenish  colour.  The  bowels  were  rather 
constipated,  and  the  evacuations  for  the  first  week  after  the  child's 
birth  continued  very  dark-coloured  :  they  afterwards  assumed  a  more 
natural  colour ;  but  the  bowels  remained  very  constipated  during  the 
whole  of  the  child's  life.  The  child  never  throve ;  it  lost  flesh,  occa- 
sionally vomited  the  milk,  had  a  frequent  and  troublesome  cough  ;  its 
strength  decayed,  and  it  died  exhausted  on  April  28,  1846,  at  the  age 
of  seven  months.  On  examining  the  body,  nothing  was  found  to 
explain  the  child's  illness :  there  was  no  tubercle  in  any  organ ;  the 
viscera  were  anaemic ;  no  trace  of  inflammatory  action  was  visible  any- 
where. A  few  lobules  in  both  lungs  were  in  a  collapsed  condition  ;  the 
small  intestine  presented  several  recent  intussusceptions ;  and  the 
stomach  was  remarkably  small,  and  undeveloped  in  form  as  well  as  in 
size  ;  but  no  other  morbid  appearance  existed  in  any  part  of  the  body. 
In  the  second  case,  the  child,  likewise  a  boy,  had  perfectly  good 
health,  till  he  was  two  months  old,  when  he  began  to  appear  stuffed  at 
his  chest,  and  had  frequent,  though  not  severe  cough.  At  the  age  of 
ten  weeks,  he  brought  up  a  small  quantity  of  dark  blood  while  cough- 
ing, and  afterwards  had  frequent  attacks  of  retching  and  vomiting, 
independent  of  cough.  During  these  attacks  he  brought  up  a  dark  red 
fluid,  like  blood,  sometimes  in  as  large  a  quantity  as  two-thirds  of  a 
teacupful.     On  Feb.  17th,  1844,  after  these  symptoms  had  continued 


H^EMATEMESIS   AND   MELvENA.  369 

for  four  days,  I  saw  the  child,  whose  face  was  slightly  flushed,  and  the 
expression  of  his  countenance  dull.  His  abdomen  was  full  and  rather 
tender,  especially  in  the  right  hypochondriac  region;  his  urine  was 
very  high  coloured,  and  his  evacuations  were  quite  white.  From  Feb. 
17th  to  April  13th,  the  child  remained  under  my  care,  and  during 
this  time  the  above-mentioned  symptoms  continued,  although  with  a 
gradual  amelioration  in  the  child's  condition.  Within  a  week  after  I 
first  saw  him,  he  had  a  severe  convulsive  seizure,  and  attacks  of  a 
similar  kind  occurred  a  great  many  times  afterwards,  independent  of 
any  obvious  cause.  The  bowels  were  always  constipated  ;  the  evacua- 
tions usually  very  white,  though  occasionally  almost  black,  sometimes 
accompanied  with  a  slight  discharge  of  blood  ;  and  blood  was  now  and 
then  voided  unmixed  with  faecal  matter.  The  stomach  became  very 
irritable,  and  the  child  suffered  from  frequent  vomiting  ;  the  matters 
rejected  being  untinged  with  blood  for  days  together,  and  then,  without 
any  apparent  reason,  blood  was  abundantly  mingled  with  them.  Some- 
times the  infant  cried  much,  and  appeared  in  very  great  pain,  and 
these  attacks  often  terminated  in  the  rejection  of  a  considerable  quan- 
tity of  nearly  pure  blood.  The  face  soon  lost  its  flush,  and  became 
pale ;  but  the  puffiness  continued,  and  was  evidently  due  to  a  slight 
degree  of  anasarca.  From  the  tender  age  of  the  child,  I  was  unable 
to  obtain  any  of  his  urine,  in  order  to  ascertain  whether  or  not  it  con- 
tained albumen.  The  treatment  followed  was  directed  to  diminish  the 
abdominal  tenderness,  by  the  application  of  a  couple  of  leeches  over 
the  right  hypochondrium,  and  to  overcome  the  constipated  state  of  the 
bowels,  and  induce  the  healthy  action  of  the  liver,  by  the  employment 
of  small  doses  of  mercurials,  and  of  the  sulphate  of  magnesia,  to 
which  it  became  sometimes  necessary  to  add  the  administration  of  an 
active  purgative.  In  May,  1844,  the  child  was  sent  to  Margate, 
where  the  convulsive  attacks,  and  the  other  symptoms,  altogether 
ceased.  On  his  return  to  London,  after  a  stay  of  six  months  at  the 
sea-side,  his  health  failed, — partly,  as  it  seemed,  in  consequence  of  his 
mother's  poverty  preventing  her  from  supplying  him  with  proper  food. 
In  Nov.  1846,  when  much  out  of  health,  and  suffering  from  diarrhoea, 
he  came  again  under  my  care,  but  died  suddenly  of  haemorrhage  into 
the  arachnoid.1  There  was  no  appearance  in  the  abdominal  viscera 
after  death  which  threw  any  light  on  the  cause  of  the  haematemesis 
and  melaena,  from  which  the  child  had  suffered  for  so  many  months 
during  his  early  infancy. 

The  subject  of  the  third  observation  was  a  little  boy,  the  child  of  a 
healthy  father  but  strumous  mother,  who  had  thriven  well  at  the 
breast  till  he  was  four  months  old,  when  he  cut  some  of  his  incisor 
teeth;  and  his  health  had  seemed  less  good  since  that  period.  There 
was,  however,  no  marked  ailment  until  he  was  weaned,  at  nine  and  a 
half  months  ;  but  after  that  he  drooped,  became  much  less  cheerful,  and 
his  evacuations  were  seen  to  be  white  and  unhealthy.  He  was  in  this 
condition  when  ten  months  and  a  week  old ;  his  abdomen,  though 
large,  was  generally   soft ;  but  pressure    in  the   left  hypochondrium 

1  The  particulars  of  his  last  illness  are  given  in  Lecture  IV.  p.  53. 
24 


370  ILLUSTRATIVE   CASES. 

seemed  to  give  pain  ;  and  careful  examination  detected  a  tumor  there 
of  the  size  of  a  small  apple.  On  the  evening  of  the  same  day  on  which 
he  was  first  seen,  the  bowels  having  acted  spontaneously  in  the  morn- 
ing, the  child  suddenly,  and  without  any  effort  or  straining,  voided 
between  three  or  four  ounces  of  pure  blood,  partly  fluid,  partly  coagu- 
lated. The  discharge  of  blood  occasioned  faintness,  and  left  the  child 
very  pallid,  but  apparently  not  suffering.  He  slept  tolerably  well 
during  the  night,  but  the  ensuing  morning,  at  7  A.  M.,  voided  nearly 
the  same  quantity  of  blood  as  on  the  previous  evening,  unmixed  with 
faeces,  but  apparently  somewhat  diluted  with  intestinal  mucus.  Some 
warm  water  thrown  up  the  bowel  returned,  stained  with  blood,  but 
unmixed  with  faecal  matter;  as  did  a  second  enema  administered  six 
hours  afterwards.  In  the  course  of  the  same  day  he  had  two  scanty 
evacuations,  both  composed  almost  entirely  of  bloody  mucus,  and  with 
such  slight  admixture  of  adhesive,  white,  faecal  matter,  almost  like 
putty  in  appearance,  that  I  did  not  feel  my  anxiety  lest  the  case  should 
turn  out  to  be  one  of  intussusception  of  the  intestines  entirely  removed 
until  nearly  twenty-four  hours  afterwards,  when,  after  a  dose  of  castor 
oil,  two  tolerably  healthy  evacuations  were  passed.  The  tenderness  of 
the  abdomen  had  now  completely  subsided,  the  swelling  in  the  left 
hypochondrium  (possibly  the  enlarged  and  congested  spleen)  had 
entirely  disappeared ;  and  the  child,  in  spite  pf  the  quantity  of  blood 
it  had  lost,  appeared  much  better  than  before  the  haemorrhage  occurred. 
This  amendment,  however,  was  not  of  long  duration  ;  no  haemorrhage, 
indeed,  returned,  but  the  child  had  an  attack  of  very  severe  diarrhceal 
attended  with  great  emaciation  and  much  abdominal  pain,  which  lasted 
for  nearly  six  weeks.  After  the  diarrhoea  ceased,  the  child  still  con- 
tinued weak,  and  thin,  and  suffering,  and  died  convulsed  in  the  middle 
of  June,  after  vague  head  symptoms  of  two  days'  duration. 

In  this  last  case  no  post-mortem  examination  could  be  made,  so  that 
we  are  uncertain  what  connection,  if  any,  subsisted  between  the 
haemorrhages  at  the  outset  of  the  child's  illness,  and  the  obstinate 
diarrhoea  which  came  on  soon  after,  and  had  so  large  a  share  in 
occasioning  its  death.  One  thing,  at  any  rate,  these  cases  illustrate, 
and  one  worth  bearing  in  mind, — viz.  that  formidable  as  the  occurrence 
is,  and  large  as  the  quantity  of  blood  which  is  lost  may  be,  still  the 
immediate  danger  to  life  is  far  less  than,  but  for  this  evidence  to  the 
contrary,  we  should  most  naturally  apprehend. 

It  will  not  be  necessary  to  do  more  than  allude  to  cases  of  what  has 
been  called  spurious  hoematemesis,  in  which  an  infant  vomits  blood 
drawn  from  some  crack  or  ulceration  of  its  mother's  nipple,  or  which 
has  been  furnished  by  some  little  vessel  cut  in  dividing  the  fraenum 
linguae,  or  in  performing  some  other  operation  on  its  mouth.  You 
would  at  once  suspect  the  source  of  the  blood  vomited  after  the  opera- 
tion on  the  infant's  mouth  ;  and  an  examination  of  the  mother's  nipple, 
in  a  case  of  haematemesis  will  guard  you  against  the  other  possible 
source  of  error. 


ICTERUS   OF   NEW  BORN   CHILDREN.  371 


LECTUER    XXXI. 

Icterus  of  New  born  Children — generally  a  trivial  affection — not  usually  dependent 
on  intestinal  disorder,  but  on  imperfect  performance  of  function  of  skin  and  respiratory 
organs — sometimes  results  from  absence  or  closure  of  hepatic  or  cystic  ducts — is  then 
associated  with  great  tendency  to  haemorrhage,  and  proves  speedily  fatal.  It  occa- 
sionally occurs  in  children  under  the  same  circumstances  as  in  the  adult. 

Constipation  sometimes  results  from  mechanical  obstruction  of  intestines — which  may 
be  congenital — as  from  imperforate  anus,  or  impervious  rectum. — Varieties  of  these 
malformations — their  general  symptoms — special  signs  of  each — their  comparative 
danger,  and  appropriate  treatment. 

Obstruction  of  intestines  from  causes  not  congenital — strangulated  hernia  very  rare  in 
infancy — intussusception  of  intestines — its  symptoms — usually  more  characteristic 
than  in  the  adult — its  generally  fatal  result — but  occasional  spontaneous  cure. 

It  often  happens,  that,  some  two  or  three  days  after  birth,  the  skin 
of  a  new-born  infant  assumes  more  or  less  of  a  yellow  colour, — that 
this  colour  gradually  deepens,  and  becomes  apparent  in  the  conjunctiva 
as  well  as  over  the  whole  surface  of  the  body ;  but  after  a  day  or  two 
the  yellow  tinge  diminishes,  and  in  the  course  of  a  week  or  ten  days 
completely  disappears — little  if  any  indisposition  having  attended  any 
stage  of  the  affection.  The  general  resemblance  of  its  symptoms  to 
those  of  jaundice  in  the  adult,  has  led  some  persons  to  attribute  this 
icterus  neonatorum  to  retention  of  the  meconium,  or  to  gastric  or  intes- 
tinal disorder  produced  by  unsuitable  food.  On  the  other  hand,  the 
slightness  of  the  constitutional  disturbance  which  attends  it,  and  the 
occasional  absence  of  all  signs  of  disorder  of  the  general  health,  have 
given  rise  to  a  different  opinion,  according  to  which  the  occurrence  is 
attributed  to  physiological  rather  than  to  pathological  causes.  With 
reference  to  the  first  of  these  views,  it  may  be  observed  that  infantile 
icterus  is  often  unattended  either  with  retention  of  the  meconium,  or 
with  any  other  form  of  intestinal  disorder ;  while  very  serious  distur- 
bance of  the  digestive  organs,  or  even  complete  retention  of  the  meco- 
nium, from  an  impervious  condition  of  the  rectum,  may  exist  without 
being  associated  with  a  yellow  tinge  of  the  skin.  The  assumption  that 
it  is  a  perfectly  natural  state,  in  which  the  skin  and  other  secreting 
organs  are  called  on  for  a  few  days  to  assist  in  disposing  of  the  bile, 
until  the  demand  for  it  to  minister  to  the  digestive  functions  becomes 
equal  to  its  abundant  supply,  is  shown  to  be  erroneous,  by  the  circum- 
stance that  jaundice  does  not  affect  perfectly  healthy  children,  who 
have  been  born  at  the  full  time,  have  been  nourished  exclusively  at  the 
mother's  breast,  and  been  sheltered  from  cold  without  being  overbur- 
thened  with  clothing  or  confined  in  a  vitiated  atmosphere.  In  the 
Dublin  Lying-in-Hospital,  where  the  children  are  defended  by  the  most 
watchful  care  from  the  evils  either  of  cold  or  of  a  vitiated  atmosphere, 
the  occurrence  of  infantile  jaundice  is  rare ;  while  in  the  Foundling 
Hospital  at  Paris  jaundice  is  so  common,  that  comparatively  few 
infants  escape  it.  Almost  all  the  children  at  the  Foundling  Hospital 
have  been  exposed  to  the  action  of  cold  while  being  brought  to  the 


372  INFANTILE  JAUNDICE   GENERALLY  OF   LITTLE   MOMENT. 

institution,  and  suffer  from  the  combined  influences  of  cold  and  bad  air 
while  inmates  of  it, — causes  which  interfere  very  seriously  with  the 
due  performance  of  the  functions  of  the  skin  and  of  the  respiratory 
organs. 

The  children  in  whom  jaundice  is  most  frequent  and  most  intense, 
are  the  immature  and  the  feeble  ;  while  in  none  is  it  so  often  met  with, 
or  in  such  an  intense  degree,  as  in  infants  affected  with  induration  of 
the  cellular  tissue,  in  whom  the  yellow  colour  is  often  so  deep  as  to  be 
manifest  in  the  serum  infiltrated  into  their  cellular  tissue,  or  poured 
out  into  the  cavities  of  their  chest  or  abdomen.  Interruption  of  the 
function  of  the  skin,  and  great  impairment  of  that  of  the  lungs,  are, 
as  you  know,  the  grand  characteristics  of  that  affection ;  while  in  many 
instances  of  it  the  foetal  passages  are  still  pervious,  and  the  blood 
circulates  in  part  through  channels  which  ought  to  have  been  closed 
from  the  time  of  birth.  These  facts  seem  to  substantiate  the  opinions 
entertained  by  many  writers  of  high  authority,  that  the  jaundice  of 
young  children  is  not  due  to  any  cause  'primarily  seated  in  the  liver, 
but  rather  to  the  defective  respiration  and  the  impaired  performance 
of  the  function  of  the  skin,  of  which  the  hepatic  disorder  and  conse- 
quent jaundice  are  but  the  effects. 

As  the  respiratory  function,  and  that  of  the  skin,  increase  in  activity 
— which  they  will  do  if  the  cause  of  their  imperfect  performance  be 
but  slight  or  temporary — the  jaundice  disappears  of  its  own  accord. 
Great  attention  must  be  paid  during  its  continuance  to  avoid  exposure 
of  the  child  to  cold ;  while  no  other  food  than  the  mother's  milk  should 
be  given.  If  the  bowels  be  at  all  constipated,  a  grain  of  Hyd.  c. 
Creta  may  be  given,  followed  by  a  small  dose  of  castor  oil ;  and  the 
aperient  will  often  seem  to  hasten  the  disappearance  of  the  jaundice  ; 
but  in  a  large  number  of  cases  even  this  amount  of  medical  inter- 
ference is  not  needed. 

Besides  these  cases,  however,  in  which  the  jaundice  is  at  most  but  a 
very  trivial  ailment,  instances  are  sometimes  met  with  where  it  is  a  very 
serious  affection,  dependent  on  congenital  absence  of  the  hepatic  or 
cystic  biliary  ducts,  or  on  the  obstruction  of  those  ducts  by  inspissated 
bile.  Under  these  circumstances  death  takes  place  sooner  or  later, 
though  now  and  then  not  for  several  months  ;  and,  as  might  be 
expected,  the  evacuations  continue  during  the  whole  period  destitute  of 
bile.  One  remarkable  phenomenon  attending  these  cases  is  the  ten- 
dency to  haemorrhage  by  which  they  are  characterized ;  this  haemor- 
rhage taking  place  for  the  most  part  from  the  umbilicus,  either  before 
or  soon  after  the  separation  of  the  funis.  In  some  instances  the  recur- 
rence of  this  bleeding  proves  fatal,  while  in  others  the  infant  sinks  into 
a  state  of  coma,  which  continues  for  a  day  or  two  before  death  takes 
place.  It  is  unusual  for  the  infant  to  survive  its  birth  longer 
than  a  fortnight ;  and,  if  its  life  should  be  prolonged,  a  condition  of 
general  atrophy  comes  on,  attended  with  enlargement  of  the  abdomen 
in  both  hypochondriac  regions  ;  and  some*  intercurrent  attack  of  diar- 
rhoea generally  exhausts  the  feeble  powers  when  only  a  few  months 
have  passed.  It  may  suffice  just  to  have  referred  to  the  main  features 
of  these  unfortunate  cases.     Happily  they  are  very  rare ;  no  instance 


OCCASIONALLY  A   DANGEROUS   AFFECTION.  373 

of  them  has  come  under  my  own  notice,  but  you  will  find  a  very  inte- 
resting history  of  three  cases  of  this  fatal  icterus  in  a  paper  published 
by  Dr.  A.  B.  Campbell,  in  the  Northern  Journal  of  Medicine  for 
August,  1844.1 

Jaundice  may  also  occur  in  older  children  under  the  same  circum- 
stances as  in  adults,  and  associated  with  similar  symptoms  ;  the  evacua- 
tions being  white,  the  urine  high  coloured,  and  more  or  less  pain  and 
tenderness  being  experienced  in  the  hypochondriac  region.  Such  cases 
are  most  frequently  met  with  during  the  summer  or  autumn,  especially 
at  times  when  diarrhoea  is  prevalent ;  the  skin  sometimes  assuming  a 
generally  yellow  tinge  as  the  purging  subsides ;  while  in  other  instances 
the  jaundice  occurs  as  an  idiopathic  aifection,  though  apparently  due  to 
the  same  causes  as  have  produced  diarrhoea  in  other  children. 

In  the  instances  that  have  come  under  my  notice  the  skin  has  never 
assumed  a  very  deep  yellow  tinge,  and  the  constitutional  symptoms 
have  seldom  been  severe.  Now  and  then,  however,  considerable  febrile 
disturbance  precedes  the  appearance  of  the  jaundice  for  two  or  three 
days  :  the  skin  is  dry,  though  not  very  hot ;  vomiting  occurs  ;  and  the 
child  complains  much  of  headache  and  dizziness,  and  rests  ill  at  night, 
or  awakes  in  a  state  of  alarm.  The  resemblance  between  these  symp- 
toms and  some  of  those  which  occur  in  cases  of  real  cerebral  disease  is 
almost  sure  to  excite  much  apprehension  in  the  mind  of  the  parents ; 
and  may  even  render  it  a  difficult  task  for  you  to  form  a  correct  diag- 
nosis. The  following  circumstances  will,  however,  usually  suffice  to 
preserve  you  from  error : — The  attack  has  not,  in  most  instances,  been 
preceded  by  those  indications  of  generally  failing  health  which  so  often 
occur  during  many  days  before  the  symptoms  of  hydrocephalus  mani- 
fest themselves  ;  and  it  is  not  attended  either  by  the  anxious  expression 
of  countenance,  the  heat  of  head,  or  the  intolerance  of  light,  by  which 
cerebral  disease  is  accompanied.  Though  the  sleep  may  be  disturbed, 
it  is  usually  less  so  than  in  hydrocephalus  ;  the  pulse  is  less  frequent ; 
and  though  the  child  vomits  occasionally,  it  does  not  suffer  from  con- 
stant nausea.  When  to  these  symptoms  tenderness  on  pressure  in  the 
hypochondriac  region  is  superadded,  with  the  appearance  in  a  day  or 
two  of  high-coloured  urine  and  of  white  evacuations,  and  lastly,  of  the 
yellow  tinge  of  the  skin,  no  further  possibility  of  error  remains. 

The  treatment  of  jaundice  in  the  child  calls  for  but  very  simple 
remedies.  If  it  be  accompanied  with  much  tenderness  in  the  hypo- 
chondriac region,  a  few  leeches  may  be  applied  in  that  situation  with 
much  advantage.  If,  however,  this  be  not  the  case,  the  employment  of 
small  doses  of  the  sulphate  of  magnesia,  in  combination  with  the  tinc- 
ture of  rhubarb,  every  four  or  every  six  hours,  with  three  grains  of  the 
Hyd.  c.  Creta"  for  a  child  of  five  years  old,  at  bed-time,  will  generally 
suffice  to  restore  the  patient  to  health  in  the  course  of  four  or  five  days. 
Should  the  appetite  continue  bad,  and  the  child  fretful  and  languid, 
after  the  subsidence  of  the  jaundice,  and  the  return  of  the  evacuations 

1  The  valuable  paper  of  Mr.  Ray,  in  Med.  Gazette  for  March,  1849  ;  that  of  Dr.  Manley 
in  the  same  journal  for  May,  1850;  and  the  essay  of  M.  E.  Dubois,  in  the  Arch.  Gen.  de 
Medicine  for  October,  1849,  furnish  a  very  complete  account  of  umbilical  haemorrhage 
in  the  infant. 


374  CONSTIPATION — 

to  a  more  healthy  character,  the  compound  infusion  of  roses,  either 
alone  or  in  combination  with  small  doses  of  sulphate  of  magnesia,  will 
be  found  of  much  service.  In  some  cases,  however,  removal  to  the 
country,  or  to  the  sea-side,  appears  to  be  absolutely  necessary  to  the 
child's  complete  recovery. 

I  have  nothing  to  add  to  what  has  already  been  said  on  the  subject 
of  constipation, — which  is  to  be  regarded  as  a  symptom  of  various 
diseases  rather  than  as  a  special  idiopathic  affection.  To  this  rule, 
however,  an  exception  must  be  made  in  those  cases  in  which  the  due 
action  of  the  bowels  is  prevented  by  some  mechanical  impediment. 
Such  an  impediment  is,  in  some  rare  instances,  presented  by  congenital 
malformation  of  the  intestines,  whose  calibre  has  been  found  greatly 
diminished,  or  their  canal  completely  obstructed,  or  even  their  conti- 
nuity altogether  interrupted.  These  occurrences,  although  of  great 
interest  and  importance,  from  their  relation  to  the  laws  that  regulate 
foetal  development,  yet  for  the  most  part  afford  no  scope  for  the  inter- 
ference of  medical  or  surgical  skill.  But  while  we  pass  over,  as  foreign 
to  our  purpose,  the  general  study  of  these  malformations,  we  must  take 
some  notice  of  one  variety  of  them,  in  which  the  obstacle  to  the  escape 
of  the  faeces  is  situated  low  down  in  the  large  intestine,  since  their 
diagnosis  is  often  easy,  and  their  cure  not  always  beyond  the  resources 
of  our  art. 

The  cause  of  the  obstruction  in  these  cases  is  not  always  of  the  same 
kind,  nor  is  the  patient  in  every  instance  exposed  to  the  same  amount 
of  danger.  But  three  different  classes  of  the  malformation  may  be 
recognized,  in  each  of  which  our  prognosis  must  somewhat  differ, 
although  in  almost  all  it  must  be  doubtful,  and  in  many  extremely 
unfavourable. 

To  the  first  class  may  be  referred  all  those  cases  in  which  the  rectum 
is  perfect,  but  the  canal  is  closed  either  by  a  false  membrane  obstruct- 
ing its  orifice,  or  situated  higher  up  in  the  intestine ;  or  by  the  cohesion 
of  the  opposite  sides  of  the  gut. 

The  second  class  includes  cases  in  which,  although  the  natural  aper- 
ture is  absent,  yet  the  intestine  terminates  by  opening  into  the  urethra, 
bladder,  or  vagina. 

To  the  third  class  belong  those  instances  in  which  the  intestinal 
canal  is  not  merely  occluded,  but  also  malformed,  or  altogether  absent 
for  a  more  or  less  considerable  extent. 

The  affection  in  any  form  is  so  rare,  as  to  render  a  correct  estimate 
of  the  comparative  frequency  of  its  varieties  by  no  means  easy.  Dr. 
Collins  observed  only  one  instance  of  it  out  of  16,654  children  born  in 
the  Dublin  Lying-in  Hospital  during  his  mastership  ;*  and  Dr.  Zohrer, 
of  Vienna,2  mentions  that  he  met  with  it  only  twice  out  of  50,000  new- 
born children.  A  comparison  of  74  cases  derived  from  different  sources 
yields  17  belonging  to  the  first  class,  29  to  the  second,  and  28  to  the 
third  ;  but  it  is  probable  that  many  instances  of  simple  closure  of  the 
anus  have  passed  unrecorded,  while  all  the  instances  of  more  serious 
malformation  have  been  described. 

1  System  of  Midwifery,  p.  509. 

2  Oesterr.  med.  Wochenschr. ;  and  Canstatt's  Jahresber.  fur  1842,  Bd.  i.  S.  456. 


FROM   MALFORMATION   OF   THE   INTESTINES.  375 

Whatever  be  the  seat  of  the  obstruction,  its  existence  is  betrayed  by 
much   the  same  train  of  symptoms  in  all  cases.     Attention   is   first 
excited  by  the  infant  not  having  voided  any  meconium,  although  from 
twelve  to  twenty-four  hours  may  have  elapsed  since  its  birth.     A  dose 
of  castor  oil,  or  of  some  other  aperient,  given  with  the  view  of  exciting 
the  bowels  to  action,  fails  of  producing  this  effect,  while  it  is  either 
returned  by  vomiting,  or,  if  not  actually  rejected,  it  causes  nausea  and 
retching.     Before  long,  the  child  shows  indications  of  uneasiness,  and 
has  attacks  of  pain,  in  which  it  cries,  and  seems  to  suffer  much.     In 
some  cases  it  remains  quiet  in  the  intervals  between  these  attacks,  and 
seems  drowsy  ;  but  in  other  cases  it  appears  to  be  in  a  state  of  constant 
discomfort,  which  it  betrays  by  a  whimpering  cry.     The  attempt  to 
suck  is  almost  always  followed  by  retching,  frequently  by  actual  vomit- 
ing ;  and  attacks  both  of  retching  and  vomiting  often  come  on  when 
the  stomach  is  quite  empty.     In  some  cases  nothing  more  is  thrown  up 
than  a  little  mucus,  which  is  sometimes  of  a  greenish  colour;  while  in 
other  instances  vomiting  of  meconium  takes  place  ;  but  this  occurrence 
is   by   no   means  constant.       The    abdomen  becomes    distended   and 
tympanitic,  and  grows  larger  and  more  tense  the  longer  that  life  con- 
tinues, while  at  the  same  time  the  child's  discomfort  is  much  aggravated 
by  any  pressure  upon  it.     The  restlessness  increases,  and  the  attacks 
of  pain   grow  more  severe,  the  child  often  making  violent  straining 
efforts  during  their  continuance ;  but  as  the  powers  of  life  decline  these 
efforts  become  more  feeble,  though  the  retching  and  vomiting  often 
continue  to  the  last.     The  period  at  which  death  takes  place  varies 
much  ;  for  though,  in  the  majority  of  instances,  the  child  dies  within  a 
week  from  its^birth,  yet  cases  are  on  record  in  which  it  has  survived 
for  several  weeks  ;  and  an  instance  has  been  mentioned  to  me  by  Mr. 
Arnott,  in  which  he  saw  a  child  live  for  seven  weeks  and  three  days, 
although  the  colon  terminated  in  a  blind  pouch,  and  the  rectum  was 
entirely  absent.     Death  usually  occurs  under  a  gradual  aggravation  of 
the  previous  symptoms  ;    but  now  and  then  it  is  ushered  in  by  the 
sudden  supervention  of  a  state  of  collapse,  owing  to  the  over-distended 
intestine  having  given  way.     This  is,  however,  a  rare  occurrence  ;  for 
I  find  mention  of  it  having  happened  only  in  three  out  of  the  seventy- 
four  cases  to  which  I  have  referred. 

Coupled  with  the  general  signs  of  intestinal  obstruction,  there  are  in 
each  case  some  special  indications  of  the  peculiar  form  of  malformation 
to  which  the  obstruction  is  due.  If  the  anus  be  merely  closed  by  a 
membrane,  or  by  the  cohesion  of  its  edges,  the  collection  of  the  meco- 
nium above  may  give  rise  to  the  formation  of  a  distinct  tumor  between 
the  buttocks ;  while  sometimes  the  dark  colour  of  the  meconium  shows 
through  the  thin  integument  by  which  its  escape  is  prevented.  In  other 
cases  the  anus  itself  is  well  formed,  but  the  introduction  of  the  finger 
or  of  a  bougie  into  the  rectum  detects  the  existence  of  some  obstruction 
within  the  gut.  Again,  in  other  instances,  there  is  no  trace  of  an  anus, 
or  a  small  depression  is  all  that  marks  the  situation  which  it  should 
occupy  ;  the  rectum  either  ending  in  a  blind  pouch,  or  communicating 
with  the  vagina,  urethra,  or  bladder. 

Although  the  diagnosis  in  all  cases  is  sufficiently  easy,  yet  the  carry- 


376  VARIETIES   OF   THEIR   MALFORMATIONS, 

ing  out  the  very  obvious  indication  of  relieving  the  patient  by  providing 
for  the  escape  of  the  contents  of  the  intestines,  is  often  very  difficult ; 
and,  even  when  accomplished,  its  result  is  in  many  instances  extremely 
uncertain.  If  the  obstruction  be  situated  at  the  orifice  of  the  anus,  a 
crucial  incision  through  the  membrane  which  closes  it,  or  the  introduc- 
tion of  a  trocar,  will  afford  immediate  relief.  Our  prognosis  also  may, 
under  these  circumstances,  be  very  favourable  ;  for  of  fifteen  cases  of 
this  kind,  all  but  one  had  a  favourable  issue.  After  the  opening  has 
been  established,  however,  some  attention  must  be  paid  to  prevent  its 
becoming  closed,  or  much  contracted.  For  this  purpose  it  has  been 
recommended  that  a  tent  should  be  kept  in  the  anus  for  some  days ; 
though  to  this  it  has  been  objected  that  a  constant  straining  effort  is 
thereby  produced,  and  the  frequent  introduction  of  the  finger  or  of  a 
bougie  into  the  passage  is  therefore  recommended,  as  preferable  to 
leaving  any  body  constantly  within  it. 

If  the  obstacle  be  occasioned  by  a  membrane  seated  higher  up  in 
the  rectum,  wTe  may  still  hope  to  succeed,  though  our  prognosis  must 
be  more  guarded,  since  two  out  of  four  cases  of  this  description  had  a 
fatal  result.  In  one  of  the  fatal  cases,  it  appeared  that  rupture  of  the 
intestine  had  already  taken  place  before  any  operation  was  performed ; 
in  the  other,  the  death  of  the  child  was  accounted  for  by  the  discovery 
of  a  second  septum  higher  up  in  the  rectum  than  that  which  had  been 
divided. 

The  existence  of  an  anus,  and  a  small  extent  of  gut  above  it,  although 
a  decidedly  favourable  feature  in  a  case,  does  not  warrant  quite  so 
hopeful  a  prognosis  as  we  might  in  the  first  instance  feel  disposed  to 
adopt.  The  probabilities,  indeed,  are,  that  the  distance  is  not  great 
between  the  end  of  the  rectum  and  the  cul-de-sac  in  which  the  anus 
terminates ;  yet  a  considerable  space  may  intervene  between  the  two, 
or,  as  in  a  case  which  Mr.  Arnott  was  so  good  as  to  communicate  to 
me,  the  rectum  may  be  found  altogether  absent,  the  colon  terminating 
in  a  blind  extremity,  and  floating  loose  in  the  abdominal  cavity.  In 
the  majority  of  instances,  the  two  blind  pouches  are  connected 
together  by  the  intervention  of  an  eighth  or  a  quarter  of  an  inch  of 
dense  cellular  tissue,  which  sometimes  presents  an  almost  ligamentous 
character ;  and  in  some  cases  the  end  of  the  large  intestine  is  situated 
anterior  to  the  extremity  of  the  cul-de-sac  that  leads  from  the  anus. — 
Owing  to  this  latter  circumstance,  the  operation  for  the  relief  of  this 
condition  has  sometimes  failed ;  the  instrument,  although  introduced 
deep  enough,  yet  passing  behind  the  distended  bowel.  Out  of  nine 
cases  of  this  kind,  eight  had  a  fatal  termination ;  the  bowel  on  four 
occasions  not  having  been  reached  at  all,  while  once  the  opening  made 
in  it  was  too  small  to  allow  the  free  escape  of  the  meconium.  It  may 
be  added,  that  in  three  of  the  fatal  cases  there  existed  such  contraction 
of  the  calibre  of  different  parts  of  the  large  intestine  as  would  of  itself 
have  opposed  a  serious  obstacle  to  the  child's  recovery. 

In  twelve  cases  the  anus  was  absent,  and  in  some  of  these  instances 
no  trace  of  it  existed,  while  the  rectum  terminated  in  a  cul-de-sac  at 
from  one  to  two  inches  from  the  surface.  In  five  of  these  cases  the 
attempt  to  open  the  intestine  was  successful,  and  the  child  eventually 


AND  THEIR  COMPARATI\  h   DANGER.  377 

did  well ;  while  in  two  other  cases,  although  temporary  relief  followed 
the  operation,  yet  symptoms  of  inflammation  of  the  bowels  came  on, 
which  terminated  fatally  in  the  course  of  a  few  days.  In  three 
instances  it  was  not  found  possible  to  reach  the  bowel ;  and  in  two 
others,  although  an  opening  was  made,  yet  its  size  was  insufficient  to 
afford  a  free  vent  to  the  accumulated  meconium ;  and  the  fatal  issue, 
though  deferred,  was  not  prevented.  Failure  to  reach  the  intestine 
seems  to  have  depended  either  on  the  trocar  not  having  been  intro- 
duced sufficiently  deep,  or  on  its  having  been  directed  too  far  backwards. 
The  danger  of  haemorrhage,  or  of  wounding  the  bladder,  of  which  some 
operators  seem  to  have  been  apprehensive,  is  not  much  to  be  feared ; 
for  I  find  but  one  instance  on  record  in  which  the  bladder  was  acciden- 
tally wounded,  and  not  one  of  fatal  or  even  of  serious  haemorrhage. — 
Better  success  also  appears  to  have  been  obtained  in  those  cases  in  which 
a  sufficiently  deep  and  free  incision  was  made  with  a  bistoury  in  the 
direction  of  the  rectum,  than  in  those  in  which  a  trochar  was  at  once 
introduced.  The  suggestion  of  M.  Amussat,  that  in  these  cases  the 
blind  sac  of  the  intestine  should  be  drawn  down,  and  its  cut  edges 
attached  by  sutures  to  the  margin  of  the  external  skin,  in  order  to 
prevent  the  infiltration  of  faecal  matter  between  the  end  of  the  rectum 
and  the  wound  in  the  integuments,  and  to  diminish  the  danger  of  the 
aperture  closing,  is  worth  bearing  in  mind.  It  was  adopted  with 
apparent  advantage  by  Mr.  Waters  in  a  case  of  this  kind  recorded  by 
him  in  the  Dublin  Journal  for  May  1842,  on  which  he  operated  with 
success ;  and  I  was  a  witness  to  its  advantages  in  a  little  boy  on  whom 
Mr.  Shaw  operated  successfully  a  few  years  since  at  the  Middlesex 
Hospital.       \ 

Besides  these  cases  in  which  the  malformation  was  confined  to  the 
rectum,  I  find  mention  of  three  others  in  which  the  rectum  was  entirely 
absent,  and  the  intestine  terminated  in  a  cul-de-sac  as  high  up  as  the 
colon.  In  two  other  cases  in  which  the  attempts  to  discover  the 
rectum  failed,  the  life  of  the  child  was  preserved  by  the  establishment 
of  an  artificial  anus.  M.  Amussat  has  of  late  recommended  that  in 
all  cases  in  which  fluctuation  cannot  be  detected  through  the  skin,  an 
artificial  anus  should  at  once  be  formed  in  the  left  lumbar  region,  as 
being  a  safer  proceeding  than  the  attempt  to  open  the  bowel  from  the 
perineum.  When  we  consider,  however,  the  loathsome  nature  of  the 
infirmity  to  which  a  person  is  condemned  in  whom  an  artificial  anus 
exists,  we  shall  probably  be  disposed  still  to  regard  the  operation  for  its 
formation  as  a  last  recourse,  to  be  employed  only  in  the  event  of 
our  failing  to  discover  the  rectum  by  an  operation  instituted  on  the 
perineum. 

In  some  cases,  although  the  anus  is  absent,  yet  the  intestine  is  not 
imperforate,  but  opens  either  into  the  vagina  in  the  female,  or  into  the 
bladder  or  uretha  in  the  male  subject.  In  either  case  the  malfor- 
mation is  due  to  a  similar  cause — namely  an  arrest  of  development, 
whereby  the  separation  between  the  bowel  and  the  sinus  uro-genitalis 
has  never  been  completed.  The  malformation  in  the  female  subject 
is  not  attended  with  immediate  danger  to  life,  and  fortunately  it  admits 
of  cure  in  the  great  majority  of  instances.     I  find,  indeed,  that  in 


378  OPERATIONS   FOR   CURE   OF   IMPERFORATE   RECTUM. 

seven  out  of  ten  cases  of  this  description,  an  operation  was  attempted, 
and  that  in  every  instance  it  proved  successful.  In  some  cases  the 
mere  establishment  of  the  natural  opening  of  the  anus,  with  the 
introduction  of  a  tube  in  the  rectum,  was  sufficient  to  effect  a  cure ; 
but  a  more  complex  operation  was  in  general  necessary,  the  principle 
of  which  consisted  in  dividing  all  the  parts  from  the  vagina  into  the 
rectum ;  though  the  details  of  the  proceeding,  and  the  means  whereby 
a  re-union  of  the  two  canals  was  prevented,  varied  in  different  cases. 

The  result  is  very  much  more  unfavourable  when  a  communication 
subsists  between  the  intestine,  and  the  bladder  or  urethra  in  the  male; 
for  eight  out  of  ten  cases  of  the  former  kind,  and  the  same  number  out 
of  nine  of  the  latter  kind,  ended  in  the  death  of  the  infant.  The  con- 
nection with  the  bladder  is  generally  established  by  means  of  a  very 
slender  canal  which  enters  that  viscus  at  or  near  its  neck ;  but  in  one 
instance  in  which  the  rectum  was  wanting,  the  colon  terminated  by 
opening  with  a  wide  aperture  into  the  upper  part  of  the  bladder.  A 
slender  duct  is  likewise  the  usual  channel  of  communication  between  the 
rectum  and  the  urethra,  and  this  duct  generally  enters  the  membranous 
portion  of  the  urethra  just  in  front  of  the  prostate.  Cruveilhier,  how- 
ever, met  with  an  instance  in  which  the  rectum  opened  under  the  glans 
penis,  and  a  somewhat  similar  case,  in  which  there  was  a  small  aperture 
through  which  meconium  passed  in  front  of  the  scrotum,  came  under 
the  notice  of  Mr.  South,  and  is  mentioned  by  him  in  his  edition,  of 
Chelius's  Surgery. 

The  existence  of  a  communication  between  the  rectum  and  the  urethra, 
or  bladder,  is  generally  indicated  by  the  urine  voided  being  tinged  with 
meconium ;  but  it  seldom  happens  that  the  contents  of  the  intestines  are 
discharged  by  the  urethra  with  freedom  sufficient  to  preserve  the  child 
from  the  suffering  and  danger  that  attend  upon  an  imperforate  state  of 
the  rectum.  Even  when  life  has  been  prolonged  for  some  time,  yet  the 
infant's  death  is  merely  deferred,  for  the  symptoms  of  obstruction 
appear,  and  at  length  prove  fatal,  after  the  fasces  have  acquired  a  firmer 
consistence  than  they  possessed  during  the  first  few  months  of  existence. 
These  cases,  too,  do  not  appear  to  be  favourable  for  an  operation,  since 
the  rectum  usually  terminates  high  up,  and  in  five  out  of  ten  cases  in 
which  it  is  stated  that  the  attempt  was  made  to  puncture  the  intestine, 
this  attempt  was  unsuccessful.  In  Mr.  South's  case  the  rectum  was 
punctured  by  a  trocar  introduced  an  inch  deep,  and  though  much  diffi- 
culty was  experienced  in  keeping  the  passage  free,  yet  the  child  survived 
and  grew  up  to  manhood.  Of  the  other  two  successful  cases,  one  of 
which  is  recorded  by  Mr.  Miller,1  and  the  other  by  Mr.  Fergusson,2  both 
were  cured  only  with  much  trouble  and  difficulty.  For  a  full  account 
of  the  difficulties  these  gentlemen  had  to  contend  with,  and  the  means 
by  which  they  overcame  them,  I  must  refer  you  to  the  history  of  the 
cases  in  the  Edinburgh  Medical  Journal. 

An  insuperable  obstacle  to  the  action  of  the  bowels  may  occur  in 
children,  just  as  it  sometimes  does  in  older  persons,  either  from  the 

1  Edinburgh  Medical  and  Surgical  Journal,  No.  98,  p.  61. 

2  Ibid.  vol.  xxxvi.  p.  363. 


INTUSSUSCEPTION  OP  THE  INTESTINES.  379 

strangulation  of  an  external  hernia,  or  from  the  invagination  of  a  por- 
tion of  intestine.  Although  hernia  is  by  no  means  an  uncommon  affec- 
tion in  early  life,  yet  it  is,  I  believe,  a  very  rare  occurrence  for  the 
intestine  to  become  strangulated.  Such  an  accident,  however,  may  take 
place,  even  in  very  young  infants,  of  which  the  case  related  by  Mr. 
Fergusson,  in  which  he  operated  for  strangulated  inguinal  hernia  on  an 
infant  only  seventeen  days  old,  may  be  mentioned  as  a  striking  illustra- 
tion. Bearing  in  mind  its  possibility,  therefore,  you  would  examine  any 
infant  or  child,  in  whom  abdominal  pain,  vomiting,  and  obstinate  consti- 
pation came  on,  just  as  carefully  as  you  would  an  adult  under  similar 
circumstances,  lest  it  should  be  found  out,  when  too  late,  that  the  symp- 
toms had  been  due  to  some  unsuspected  external  hernia. 

The  strangulation  of  an  external  rupture  is  probably  a  rarer  accident 
in  early  life,  than  the  occurrence  of  intussusception  of  one  or  more 
portions  of  the  intestines.  This  condition,  indeed,  is  frequently  met 
with  in  the  bodies  of  children  who  have  died  of  various  diseases,  and 
wholly  independent  of  any  symptoms  of  disorder  of  the  bowels  during 
the  patient's  life-time.  Sometimes  a  single  intussusception  exists,  but 
oftener  there  are  several ;  ten,  twelve,  and  even  more,  have  occasionally 
been  observed  in  the  same  subject.  They  are  most  numerous  in  the 
ileum,  and  though  seldom  involving  more  than  three  or  four  inches,  have 
been  found  to  include  more  than  double  that  extent  of  intestine.  Their 
great  frequency,  the  absence  of  any  symptom  of  them  during  life,  and 
of  any  indication  of  inflammation  about  the  intestines  after  death,  all 
confirm  the  general  opinion  that  they  take  place  during  the  act  of  dying. 

It  happens,  however,  now  and  then,  that  an  infant  previously  well  is 
suddenly,  and^pparently  causelessly,  seized  with  abdominal  pain,  vomit- 
ing, and  obstinate  constipation,  attended  with  tenesmus,  and  the  dis- 
charge by  the  anus  of  small  quantities  of  blood  or  bloody  mucus,  and 
that  death  having  taken  place  under  an  aggravation  of  these  symptoms, 
an  intussusception  of  some  portion  of  the  intestine  is  discovered  on 
making  a  post-mortem  examination.  In  other  cases,  after  these  symp- 
toms have  continued  for  some  hours,  and  after  medicine  has  seemed 
altogether  unable  to  relieve  them,  the  pain  and  the  vomiting  cease,  the 
child  has  one  or  more  faecal  evacuations,  and  regains  its  usual  health 
without  the  recurrence  of  any  accident  calculated  to  renew  our  anxiety. 
It  has  been  suggested,  and  with  great  probability,  that  in  cases  of  this 
kind  an  invagination  had  existed,  which  nature  had  succeeded  in 
removing,  and  had  thus  preserved  the  infant's  life.  Be  this  as  it  may, 
neither  occurrence  is  at  all  frequent,  for  it  has  never  happened  to  me 
to  meet  with  a  case  of  fatal  intussusception,  and  the  cases  recorded  in 
medical  journals  are  not  numerous ;  whilst  I  have  observed  only  one 
instance  in  which  the  symptoms  of  intussusception  having  existed  in  a 
marked  degree,  at  length  spontaneously  ceased,  and  were  followed  by 
the  restoration  of  the  infant  to  perfect  health. 

Children  in  whom  intussusception  takes  place  are  generally  infants 
under  a  year,  often  under  six  months  old.  Their  previous  history  does 
not  in  general  display  any  liability  either  to  constipation  or  to  diarrhoea ; 
nor,  in  the  greater  number  of  instances,  has  the  manifestation  of  the 
symptoms  followed  the  administration  of  any  aperient  medicine.     Sud- 


380  ITS   SYMPTOMS. 

den  and  violent  vomiting,  followed  by  loud  cries,  and  other  indications 
of  uneasiness,  which,  ceasing  for  a  time,  return  at  uncertain  intervals, 
and  are  accompanied  by  violent  straining,  and  efforts  to  empty  the 
bowels,  are  the  earliest  symptoms  of  the  accident.  At  first  some  fasces 
are  voided  during  these  efforts,  but  afterwards  the  matters  discharged 
from  the  bowels  are  either  mucus  tinged  with  blood,1  or  else  pure  blood, 
and  that  sometimes  in  considerable  quantities.  If  an  enema  be  given, 
the  fluid  thrown  up  is  immediately  returned,  it  appearing  not  properly 
to  enter  the  intestine ;  while  on  one  or  two  occasions,  the  existence  of 
an  obstruction  has  been  discovered  on  introducing  the  finger  into  the 
rectum.  The  vomiting  is  almost  immediately  renewed  whenever  either 
food  or  medicine  is  given,  but  faecal  matters  are  seldom  if  ever  discharged 
by  the  mouth.  The  child  has  intervals  of  quiet,  from  which  it  is  roused 
by  the  returns  of  pain ;  it  is  often  thirsty,  and  though  the  sickness  con- 
tinues unabated,  yet  it  seems  eager  for  the  breast,  and  sucks  frequently. 
The  condition  of  the  abdomen  is  variable  ;  and  though  a  distinct  tumor 
is  said  to  have  been  detected  in  some. cases,  at  a  spot  which  was  found 
afterwards  to  correspond  to  the  situation  of  the  intussusception,  yet  it 
has  happened,  in  at  least  as  large  a  number  of  instances,  that  the  most 
careful  examination  has  failed  to  detect  anything  unnatural  in  its  state, 
and  that  it  has  continued  uniformly  soft  up  to  the  time  of  the  patient's 
death.  The  continuance  of  the  intussusception  leads  to  the  exhaustion 
of  the  infant's  strength ;  its  pulse  grows  more  and  more  feeble,  its  face 
becomes  anxious  and  sunken,  and  it  falls  in  the  intervals  between  its 
attacks  of  pain  into  a  quiet,  half-comatose  condition.  In  the  majority 
of  cases  convulsions  come  on  a  few  hours  before  death,  which  always 
takes  place  within  a  week,  oftener  in  from  forty-eight  to  seventy-two 
hours. 

A  portion  of  the  ileum,  the  caecum,  and  sometimes  a  portion  of  the 
ascending  colon,  are  the  parts  usually  invaginated.  In  many,  though 
not  in  all  instances,  these  parts  display  more  or  less  evidence  of  inflam- 
mation, which  sometimes  is  found  to  have  extended  to  the  peritoneum. 
The  presence  of  inflammation,  and  its  amount,  are,  as  might  be  expected, 
mainly  dependent  on  the  duration  of  the  infant's  life. 

On  comparing  the  history  of  several  cases  of  this  affection,  there 
appears  to  be  such  an  uniformity  in  their  symptoms  as  would,  I  should 
imagine,  render  it  in  general  tolerably  easy  to  form  a  correct  diagnosis. 
I  do  not  dwell  upon  the  treatment,  for  that  must  be  the  same  in  the 
infant  as  in  the  adult ;  and  my  own  experience  does  not  enable  me  to 
say  any  thing  that  could  be  of  use  in  diminishing  the  difficulties  by 
which  the  subject  is  attended.  I  would  only  observe,  that  as  the  symp- 
toms enable  you  in  the  infant  earlier  than  in  the  adult  to  arrive  at  a 
tolerably  certain  knowledge  of  the  nature  of  the  case,  you  will  have 
absolutely  no  excuse  for  persevering  in  the  use  of  active  purgatives,  in 
order  to  overcome  the  constipation.  It  was  during  the  suspension  of 
the  active  remedies  which  had  been  previously  employed,  that  the  case 

1  The  credit  of  drawing  attention  to  the  value  of  the  intestinal  haemorrhage  in  these 
cases  as  a  sign  of  intussusception,  belongs  to  Mr.  Gorham,  whose  essay  on  this  affection, 
in  No.  7  of  the  Guy's  Hospital  Reports,  may  be  consulted  with  profit. 


DIARRHC3A.  381 

which  I  saw  took  a  favourable  turn ;  and  I  should  regard  the  use  of 
powerful  cathartics  as  less  warrantable  in  the  child  than  in  the  grown 
person.  The  same  objection  could  not  attach  to  the  use  of  large 
enemata,  nor  to  the  inflation  of  the  intestine  with  air,  which  has  once 
or  twice  been  followed  by  the  subsidence  of  the  symptoms,  and  which  I 
had  proposed  employing  in  the  case  above  referred  to,  had  I  not  had  the 
pleasure  of  finding  that  nature  had  effected  the  patient's  cure. 


LECTURE  XXXII. 

Diarrhcea — its  two  forms,  the  simple  and  inflammatory — causes  of  the  affection — in- 
fluence of  age — of  process  of  dentition — of  temperature,  and  season  of  the  year. 

Symptoms  of  simple  diarrhoea — not  usually  a  dangerous  affection — occasional^  hazard 
from  great  exhaustion  that  it  produces — cessation  of  purging  sometimes  independent 
of  real  amendment — danger  of  secondary  diarrhoea. 

Inflammatory  diarrhoea — occasional  want  of  correspondence  between  the  symptoms  and 
morbid  appearances — latter  observed  chiefly  in  large  intestine — very  similar  to  those 
discovered  in  dysentery  of  the  adult. 

Symptoms  of  inflammatory  diarrhoea — occasional  disturbance  of  nervous  system  at  the 
outset — progress  of  the  disease — its  tendency  to  a  chronic  course.  Life  sometimes  cut 
short  by  intercurrent  bronchitis — by  head  symptoms — by  relapse  after  temporary 
amendment. 

In  a  systematic  course  of  lectures  like  the  present,  subjects  of  very 
various  interest  and  importance  come  successively  before  us.  We  were 
engaged  yesterday  in  the  study  of  some  affections,  which  fortunately 
are  of  very  rare  occurrence  ;  but  to-day  we  pass  to  the  examination  of 
one  of  the  most  common,  and  at  the  same  time  one  of  the  most  serious, 
disorders  of  infancy  and  childhood.  The  importance  of  diarrhoea  in 
early  life,  indeed,  is  not  to  be  estimated  merely  by  the  number  of  deaths 
which  our  tables  of  mortality  represent  it  to  have  occasioned  ;  for  the 
figures  that  they  display  would  warrant  our  dismissing  it  with  a 
comparativly  short  notice.1  But  we  shall  come  to  a  very  different 
conclusion,  if  we  consider  the  frequency  of  the  affection,  and  the  slight 
causes  which  often  suffice  to  induce  it ;  the  dangers  to  health  which 
result  from  its  long  continuance ;  and  the  greatly  increased  hazard  to 
which  its  supervention  in  the  course  of  some  other  disease  exposes  the 
patient. 

Under  the  common  name  of  diarrhoea,  many  of  the  older  writers  on 
the  diseases  of  children  have  included  all  cases,  without  distinction,  in 
which  there  is  an  unnatural  increase  in  the  alvine  discharges.  On  the 
other  hand,  some  among  the  moderns,  rejecting  the  word  diarrhcea 
from  their  medical  nomenclature,  have  treated  only  of  certain  inflam- 
matory affections  of  the  intestines  of  which  they  believe  the  flux  to  be 

i  According  to  the  Fifth  Report  of  the  Registrar-General,  the  deaths  in  London  from 
diarrhcea,  dysentery,  and  cholera,  as  compared  with  the  total  deaths  from  all  ascertained 
causes,  were,  in  children  under  one  year  old,  in  the  proportion  of  3-9  per  cent. ;  between 
one  and  three,  2-3  per  cent. ;  from  three  to  five,  *6  per  cent.  ;  from  five  to  ten,  1-1  per 
cent. ;  and  from  ten  to  fifteen,  1  •  per  cent. 


382    DIARRHCEA — ITS    TWO   FORMS — THE   SIMPLE   AND   INFLAMMATORY. 

symptomatic.  Neither  of  these  arrangements,  however,  is  free  from 
objection,  for  while  the  former  draws  no  adequate  distinction  between 
cases  in  which  the  disorder  of  the  functions  of  the  bowels  is  the  result 
of  some  accidental  and  temporary  cause,  and  others  in  which  it  is  the 
consequence  of  organic  disease,  the  latter  involves  an  attempt  to 
distinguish,  on  purely  anatomical  grounds,  between  affections  which 
present  the  same  symptoms  and  require  the  same  treatment. 

In  the  present  state  of  our  knowledge,  it  will  perhaps  be  the  safer 
way  to  attempt  no.  further  subdivision  than  into  the  two  grand  classes 
of  simple  diarrhoea,  or  catarrhal  diarrhoea,  as  it  has  been  termed  by 
some  writers,  and  inflammatory  diarrhoea  or  dysentery.  Even  in  this 
arrangement  it  must  be  confessed  that  there  is  something  arbitrary, 
for  the  two  affections  are  closely  allied  to  each  other.  In  the  child,  as 
in  the  adult,  they  often  prevail  at  the  same  time, — they  are  to  a 
considerable  degree  dependent  on  the  same  causes,  and  are  in  a  measure 
amenable  to  the  same  remedies ;  while  the  milder  complaint  not  infre- 
quently passes  into  the  more  severe.  Before  we  proceed,  therefore,  to 
the  study  of  the  spcial  charactres  of  either  affection,  it  may  be  well  to 
examineunto  some  of  those  conditions  which  are  alike  favourable  to  the 
production  of  both. 

The  following  table,  deduced  from  2129  cases  of  diarrhoea  or 
dysentery  that  came  under  my  notice  at  the  Children's  Infirmary, 
shows  that  the  age  of  the  child  has  much  to  do  with  the  occurrence  of 
the  affection: — 


of  diarrhoea  in  children  at  the 
following  ages : — 


Under        6  months 

Between    6         "     and  12  months 


12 

18         " 

2    years 

3 

5 
10 


18      '< 
2  years 


10 
15 


Were  to  all  cases  of  diarrhoea 

in  children  under  15  in 

the  proportion  of 


9*7  per  cent. 
15-7 
20-9 
13-9 
121 
11-2 
11-5 

4-7 


Were  to  all  diseases  at 

the  same  age  in  the 

proportion  of 


16-1  percent. 

20-0 

26-8 

25-4 

150 

9-3 

7-9 

7-7 


You  will  observe  that  the  period  of  the  greatest  prevalence  of 
diarrhoea  coincides  exactly  with  that  time  during  which  the  process  of 
dentition  is  going  on  most  actively,  and  that  exactly  half  of  all  cases 
of  diarrhoea  occurred  in  children  between  the  ages  of  six  months  and 
two  years.  So  close,  indeed,  is  the  connection  between  teething  and 
diarrhoea,  that  a  French  physician,  M.  Bouchut,1  found  that  only  26 
out  of  110  children  entirely  escaped  its  attack  during  the  period  of 
their  first  dentition,  while  46  suffered  from  it  very  severely.  The  older 
writers  on  medicine,  whose  notice  this  fact  did  not  escape,  attributed 
the  disturbance  of  the   bowels   to  a   sort  of  sympathy   between   the 


1  Manuel  Pratique  des  Maladies  des  Nouveaux-Nes,  12mo.  p.  19G.     Paris,  1845. 


CAUSES   PREDISPOSING  TO   DIARRHOEA.  383 

intestinal  canal  and  the  gums,  swollen  and  irritated  by  the  approach  of 
the  teeth  to  their  surface.  The  frequent  observation  of  cases  in  which  an 
attack  of  diarrhoea  attends  the  irruption  of  each  fresh  tooth,  and  ceases 
when  it  has  cut  through  the  gum,  shows  that  such  a  hypothesis  is  not 
altogether  without  foundation.  But  besides  the  influence  of  nervous 
irritation  in  quickening  for  a  time  the  peristaltic  action  of  the  bowels, 
and  thus  inducing  diarrhoea,  it  must  be  borne  in  mind  that  there  exists 
during  the  period  of  teething  a  more  abiding  cause,  which  strongly 
predisposes  to  its  occurrence.  All  parts  of  the  digestive  canal,  and  of 
its  dependencies,  are  now  undergoing  an  active  evolution  to  fit  them 
for  the  proper  assimilation  of  the  varied  food  on  which  the  young  being 
will  soon  have  to  subsist.  Just  as  the  salivary  glands  are  now  deve- 
loped, and  pour  out  saliva  in  abundance,  so  the  whole  glandular  system 
of  the  intestines  assumes  a  rapidity  of  growth,  and  an  activity  of  func- 
tion, which,  under  the  influence  of  comparatively  slight  exciting  causes, 
may  pass  the  just  limits  of  health.  In  too  many  instances,  causes  fully 
adequate  to  excite  diarrhoea  are  abundantly  supplied  in  the  excessive 
quantity  or  unsuitable  quality  of  the  food  with  which  the  infant  is  fur- 
nished; for  it  is  forgotten  that  its  condition  is  one  of  transition,  in 
which  something  more  than  ordinary  care  is  needed,  while  in  accordance 
with  that  mistaken  humoral  pathology  so  popular  among  the  vulgar, 
the  profuse  secretion  from  the  irritated  glands  is  regarded  as  the  result 
of  a  kind  of  safety-valve  arrangement,  whereby  nature  seeks  to  mode- 
rate the  constitutional  excitement  attendant  upon  teething. 

But,  besides  those  conditions  seated  within  the  organism  which  pre- 
dispose to  diarrhoea,  and  those  occasions  furnished  from  without  by  the 
food  with  which  the  child  is  supplied,  atmospheric  influences  constitute 
a  third,  and  a  Very  important  class  of  causes,  which  at  one  time  render 
diarrhoea  very  frequent,  and  at  another  greatly  check  its  prevalence. 

On  a  comparison  of  the  results  of  eight  years'  observation  at  the 
Children's  Infirmary,  I  find  that 

In  the  3  months,  Nov.,  Dec,  and  Jan.,  diarrhoea  formed  7.9  per  cent,  of  all  cases  of  disease. 
"  Feb.,  March,  and  April,  "  9.5  "  " 

"  May,  June,  and  July,  "  15.3  «•  " 

"  Aug.,  Sept.,  and  Oct.,  *  28.0  "  " 

The  above  mentioned  causes  dispose  alike  to  diarrhoea  and  dysentery ; 
but  among  the  dwellings  of  the  poor  in  this  metropolis,  and  especially 
in  that  district  of  it  where  most  of  my  observations  have  been  made, 
conditions  abound  which  often  stamp  on  the  disease  the  characters  of 
the  more  serious  malady.  Before  investigating  them,  however,  we  may 
first  study  the  symptoms  of  the  milder  affection,  which,  though  much 
the  more  frequent,  yet,  if  uncomplicated,  is  seldom  or  never  fatal. 

When  the  attack  comes  on  in  perfectly  healthy  children,  it  often  sets 
in  quite  suddenly,  with  vomiting  of  the  contents  of  the  stomach,  and 
afterwards  of  mucus,  which  sometimes  has  a  yellow  or  greenish  colour. 
The  sickness  does  not  in  general  continue,  though  exceptions  are  met 
with  in  some  of  the  more  severe  cases,  in  which  the  stomach  remains 
very  irritable  during  the  whole  period  that  the  affection  lasts.  In  either 
case,  the  vomiting  is  almost  immediately  succeeded  by  increased  action 


384  SYMPTOMS   OF   SIMPLE   DIARRH03A. 

of  the  bowels,  the  matters  discharged  being  at  first  the  healthy  faeces ; 
but  they  soon  assume  a  bright  yellow  colour,  like  that  of  the  yolk  of 
egg,  and  are  often  intermixed  with  slime ;  or  in  other  cases  they  present 
a  frothy  appearance.  The  bright  yellow  colour  of  the  evacuations, 
often,  though  by  no  means  always,  changes  to  green  under  exposure  to 
the  air  :  while,  if  the  diarrhoea  should  continue,  the  faeces  present  in 
many  instances  a  green  colour  when  voided,  similar  to  that  which  is 
frequently  produced  by  the  administration  of  mercury.  In  other  cases 
the  green  and  yellow  colours  appear  intermixed  in  the  evacuations, 
while  the  presence  in  them  of  numerous  white  specks,  the  casein  of  the 
undigested  milk,  shows  that  the  function  of  the  stomach  is  interfered 
with  by  the  same  cause  as  produces  the  over-action  of  the  bowels.  The 
source  of  the  green  colour  of  the  evacuations  has  not  yet  been  quite 
satisfactorily  determined.  In  some  cases  it  probably  depends  on  the 
action  of  the  acids  of  the  alimentary  canal  upon  the  colouring  matter 
of  the  bile ;  but  Dr.  Golding  Bird's  investigations  have  proved  it  not 
to  be  always  due  to  this  cause,  and  have  rendered  it  probable  that,  in 
many  instances,  it  results  from  the  presence  of  altered  blood  in  the 
evacuations.  As  the  child  returns  to  health,  the  faeces  become  less 
watery,  and  then  resume  their  yellow  colour;  or  stools  of  a  natural 
character  alternate  with  others  of  a  green  colour  and  unhealthy  aspect, 
or  in  which  a  very  large  quantity  of  mucus  is  present.  The  action  of  the 
bowels,  too,  becomes  less  frequent,  and  the  child  often  regains  its  usual 
health  in  four  or  five  days,  though  sometimes  a  disposition  to  diarrhoea 
is  left  behind,  and  the  disorder  is  liable  to  be  re-excited  by  very  slight 
causes. 

In  the  majority  of  cases  this  over-action  of  the  bowels  is  not  attended 
with  much  fever  or  constitutional  disturbance,  though,  if  it  should  come 
on  during  teething,  the  general  feverishness  of  the  child  is  often  some- 
what aggravated.  The  appetite  is,  usually  much  impaired,  while  the 
thirst  is  often  considerably  increased,  and  the  child  seems  very  desirous 
of  cold  water.  The  tongue  is  moist,  in  general  thinly  covered  with 
mucus,  through  which  the  papillae  appear  of  a  brighter  red  than  natural ; 
but  the  tongue  is  neither  very  red,  nor  much  coated.  The  abdomen  is 
soft,  seldom  either  full  or  painful ;  and  the  pain  which  attends  the 
diarrhoea  is  very  variable — sometimes  it  is  completely  absent,  the  stools 
being  expelled  without  either  effort  or  suffering ;  while  in  other  cases 
pain  comes  on  severely  at  intervals,  and  then  ceases  so  soon  as  the 
bowels  have  acted.  Although  there  is  seldom  much  tenesmus,  yet  a 
slight  degree  of  it  attends  upon  simple  diarrhoea  in  the  child  much 
more  frequently  than  in  the  adult.  There  is,  as  might  be  anticipated, 
a  loss  of  the  natural  look  of  health — the  face  grows  pale,  the  eyes 
appear  sunken,  and  the  child  become  fretful  and  languid, — while,  if  the 
attack  set  in  severely,  a  day  or  two  sometimes  suffices  to  reduce  the 
child  to  a  state  of  extreme  weakness  and  exhaustion ;  and  in  young 
infants,  I  have  now  and  then  observed  all  the  symptoms  of  spurious 
hydrocephalus  make  their  appearance. 

The  diarrhoea  that  occurs  in  connection  with  the  irritation  occasioned 
by  teething  is  in  general  more  gradual  in  its  onset,  and  slower  in  its 
progress,  than  that  which  depends  on  some  more  transient  cause.     It 


SOURCES   OF  DANGER   IN   ITS   COURSE.  385 

is  likewise  often  associated  with  catarrhal  symptoms ;  and  both  the 
catarrh  and  diarrhoea  freequently  continue,  until  the  tooth,  having 
pierced  the  gum,  the  irritation  of  the  mucous  membranes  subsides ;  but 
to  be  renewed  when  a  fresh  tooth  approaches  the  surface. 
•  Although  the  dangers  attendant  on  simple  diarrhoea,  especially  when 
it  occurs  in  healthy  children,  are  not  considerable,  yet  the  affection  is 
one  which  it  is  never  wise  to  make  light  of.  On  more  than  one  occa- 
sion I  have  seen  an  infant  reduced  by  it  to  a  state  of  such  extreme 
exhaustion  as  seriously  to  endanger  life.  Diarrhoea,  indeed,  is  the 
exciting  cause  of  the  greater  number  of  cases  of  that  spurious  hydro- 
cephalus,1 in  which  cerebral  disturbance  from  debility  simulates  real 
inflammatory  disease  of  the  brain.  Under  such  circumstances,  too,  the 
diarrhoea  has  not  infrequently  ceased  for  some  time  before  the  other 
more  alarming  symptoms  made  their  appearance.  The  cessation  of 
diarrhoea  may  be  due,  not  so  much  to  the  quieting  of  irritation,  as  to 
the  exhaustion  of  the  nervous  energy  which  is  essential  to  the  per- 
formance of  their  secretory  function  by  the  glands  of  the  intestines,  or 
to  the  due  maintenance  of  the  peristaltic  movements  of  the  bowels.  In 
infants  prematurely  weaned,  or  improperly  fed  after  being  taken  from 
the  breast,  we  often  see  this  fact  exemplified  in  the  cessation  some 
twelve  or  twenty-four  hours  before  death,  of  the  diarrhoea,  from  which 
they  have  been  suffering  for  weeks  together.  Nor  must  we  ever  make 
too  sure  that,  because  purging  has  ceased,  therefore  danger  is  over ;  or 
venture  to  relax  our  watchful  care,  until  the  continuance  of  amendment, 
for  twenty-four  hours  or  more,  shows  that  there  is  indeed  no  longer 
anything  to  fear. 

This,  however,  is  not  the  only  danger  to  which  previously  healthy 
children  are  exposed  by  an  attack  of  simple  diarrhoea ;  for  if  not  quickly 
checked,  it  sometimes  assumes  the  more  serious  characters  of  dysentery, 
and  occasions  severe  and  long-continued  suffering.  When  diarrhoea 
supervenes  in  children  who  are  recovering  from  some  disease,  such  as 
measles,  in  which  a  tendency  to  relaxation  of  the  bowels  often  marks 
the  period  of  convalescence,  or  who  have  been  suffering  from  a  pro- 
tracted ailment,  such  as  hooping-cough,  it  sometimes  occasions  the 
patient's  death,  although  it  may  leave  behind  in  the  intestinal  canal  no 
traces  of  serious  mischief.  Still  more  frequently  is  this  the  case  with 
infants  who  have  been  brought  up  by  hand,  or  who  have  thriven  badly 
at  the  breast.  A  troublesome  purging,  continuing  for  weeks  together, 
exhausts  the  strength  of  such  infants,  and  at  length  occasions  their 
death ;  but  yet  the  intestinal  canal  in  many  instances  presents  no  trace 
of  more  serious  mischief  than  an  unusual  degree  of  distinctness  of  the 
follicles  of  the  small  intestines,  and  of  the  solitary  glands  of  the  colon 
and  rectum. 

In  proposing  at  the  commencement  of  this  lecture,  to  distinguish 
between  simple  and  inflammatory  diarrhcea,  I  yet  was  forced  to 
acknowledge  that  the  distinction  was  one  rather  of  degree  than  of 
kind ;  or,  perhaps  it  would  be  more  correct  to  say,  that  our  observation 
has  not  hitherto  been  minute  enough  to  enable  us  to  draw  the  line  of 

1  See  Lecture  X.  p.  111. 
25 


386  INFLAMMATORY   DIARRHOEA,   OR   DYSENTERY. 

demarcation  strictly  between  the  two  affections.  Even  MM.  Hilliet 
and  Barthez,1  whose  opportunities  have  been  so  extensive,  and  whose 
industry  is  so  untiring,  confess  their  inability  to  refer  the  symptoms 
that  attend  upon  the  different  varieties  of  diarrhoea  to  any  distinct  and 
invariable  anatomical  lesions.  They  remark,  that  not  merely  are  exceed- 
ingly different  appearances  discovered  after  death  in  cases  where  the 
same  symptoms  have  been  observed  during  life,  but  that  likewise  there  is 
often  no  proportion  between  the  intensity  of  the  two  ;  and  that  some- 
times no  morbid  appearances  are  found,  even  where  well-marked  symp- 
toms had  existed.  Usually,  indeed,  in  cases  where  the  morbid  appear- 
ances are  slight,  the  symptoms  during  life  have  not  been  severe.  Occa- 
sionally, however,  the  reverse  has  occurred ;  and  the  diarrhoea  has  been 
intense,  the  pain  considerable,  and  the  abdomen  tense  and  tympanitic. 
MM.  Rilliet  and  Barthez  state,  that  out  of  127  children  who  had  died 
of  different  diseases,  84  had  presented  the  symptoms  of  inflammatory 
diarrhoea,  or  entero-colitis,  and  the  characteristic  appearances  of  that 
affection  were  manifest  on  an  examination  of  their  intestines  after  death ; 
in  24,  though  no  symptoms  had  existed  during  life,  similar  changes  were 
discovered;  while  in  19,  the  signs  of  disease  were  present  during  life, 
but  its  morbid  appearances  were  absent.  It  is  true  that  these  observa- 
tions refer  to  children  above  two  years  of  age,  and  to  cases  in  which 
diarrhoea  had  occurred  as  a  secondary  affection  ;  but  my  own  observation 
would  lead  me  to  believe  that  a  similar  statement  might  be  made  with 
reference  to  younger  children,  and  to  cases  of  idiopathic  diarrhoea. 

These  circumstances  prevent  our  deducing  from  the  results  of  anato- 
mical investigation  those  practical  conclusions  which  we  should  other- 
wise be  inclined  to  draw  from  them;  but  they  do  not  warrant  us  in 
altogether  omitting  to  inquire  what  changes  we  shall  be  most  likely 
to  meet  with  in  cases  of  fatal  diarrhoea. 

These  changes  will  be  found  chiefly,  though  not  exclusively,  in  the 
larger  intestine;  and  though  usually  much  less  serious  than  those 
which  are  observed  in  cases  of  fatal  dysentery  in  the  adult,  they  yet 
present  very  similar  characters.  In  those  cases  in  which  the  structural 
alterations  have  been  least  considerable,  the  attention  is  arrested  less 
by  any  great  increase  of  vascularity  in  the  intestine,  than  by  the 
remarkable  distinctness  of  the  orifices  of  the  solitary  glands  which 
appear  like  almost  innumerable  dark  spots  upon  the  surface  of  the 
mucous  membrane.  In  many  cases,  and  especially  in  those  in  which 
the  diarrhoea  was  profuse  at  the  time  of  the  patient's  death,  not 
merely  are  the  openings  of  these  follicles  unusually  distinct,  but  the 
glands  themselves  are  enlarged,  and  project  like  small  millet-seeds,  or 
small  pin's  heads,  beyond  the  level  of  the  surrounding  tissue.  This 
enlargement  of  the  solitary  glands  is  usually  associated  with  increased 
vascularity  of  the  mucous  membrane  ;  which  does  not  however,  assume 
the  characters  of  a  general  erythematous  redness,  but  it  is  confined  to 
that  part  of  the  membrane  which  covers  each  gland,  or  which  surrounds 
its  base.  If  the  disease  advance  further,  ulceration  succeeds  to  this 
inflammation  of  the  glands.     A  small,  circular,  or  slightly  oval  spot, 

1  Op.  cit.  tome  i.  p.  509-12. 


MORBID  APPEARANCES  IN   THE   LARGE    INTESTINE.  387 

appears  upon  their  summit  and  increases  in  size  and  depth,  until  it  has 
destroyed  the  glandular  structure  and  the  mucous  membrane,  and  Has 
produced  a  deep  cup-like  depression  or  ulceration,  the  base  of  which 
is  formed  by  the  muscular  coat  of  the  intestine.  On  one  occasion  I 
observed,  in  the  midst  of  enlarged  and  ulcerated  glands,  some  others 
equally  large,  but  on  which  the  excavated  ulcer  had  not  yet  formed ; 
their  summit  presenting  a  small  round  or  oval  spot,  of  a  yellowish 
colour — most  probably  a  minute  slough  not  yet  detached  from  the 
surface.  Besides  that  loss  of  substance  which  results  from  the 
ulceration  or  sloughing  of  the  glands  themselves,  a  process  of  thinning 
and  destruction  likewise  affects  other  parts  of  the  mucous  membrane, 
especially  in  those  situations  which  correspond  to  the  edges  of  the 
intestinal  rugae.  In  some  parts  the  membrane  appears  to  be  merely 
attenuated,  while  in  others  it  seems  to  have  entirely  disappeared, 
though  the  limits  of  its  destruction  are  not  marked  by  the  same  well- 
defined  edges  as  circumscribe  the  ulcers  of  the  glands ;  nor  is  the  loss 
of  substance  so  deep.  On  the  inner  surface  of  an  intestine  thus 
affected  may  be  seen  a  number  of  narrow,  white,  lines,  enclosing 
between  them  islets  of  mucous  membrane ;  and  often  having  such  an 
arrangement  as  to  give  to  those  portions  of  membrane  the  form  of 
irregular  parallelograms.  This  superficial  destruction  of  the  mucous 
coat  of  the  intestine  is  often  much  more  complete  in  the  rectum,  and 
in  the  sigmoid  flexure  of  the  colon,  than  elsewhere ;  and  when  this 
is  the  case  the  surface  of  the  bowel  presents  an  uniformly  rcugh 
appearance.  It  is  also  in  the  lower  part  of  the  large  intestine  that 
the  ulcerative  process  is  most  frequent  and  most  extensive ;  and  if 
care  be  not  taken  to  examine  the  last  few  inches  of  the  rectum,  we 
may  come  to  the  mistaken  conclusion  that  ulceration  is  altogether 
absent,  in  cases  where  more  careful  investigation  would  have  easily 
convinced  us  of  its  existence.  On  one  occasion,  I  found  the  disease 
in  the  lower  part  of  the  large  intestine  to  be  so  far  advanced  that 
the  interior  of  the  sigmoid  flexure  of  the  colon  and  of  the  rectum 
presented  an  irregular  tuberculated  surface,  of  an  ash-grey  colour, 
which  appeared  eaten  into  holes  by  a  number  of  small,  circular  pits, 
or  ulcers,  with  sharply  cut  edges.  Besides  these  changes  in  the 
interior  of  the  large  intestine,  a  thickening  of  its  submucous  coat  is 
almost  always  observable,  whenever  the  diarrhoea  has  continued  for 
any  considerable  length  of  time.  It  is  in  the  rectum  and  sigmoid 
flexure  of  the  colon  that  this  thickening  is  most  perceptible ;  and  in 
this  situation  a  gelatinous-looking  matter  is  sometimes  deposited  in 
such  abundance  beneath  the  mucous  membrane  as  to  prevent  the 
intestine  from  becoming  collapsed  when  it  is  divided. 

But  it  is  not  merely  in  the  morbid  appearances  presented  by  the 
large  intestines,  but  also  in  the  subsidiary  changes  observed  in  other 
parts  of  the  intestinal  canal,  that  the  close  relation  is  manifested 
between  the  diarrhoea  of  the  infant  and  the  dysentery  in  the  adult. 
The  changes  in  the  small  intestine  are  almost  always  confined  to  the 
lower  part  of  the  ileum,  and  become  more  striking  the  nearer  we 
approach  to  the  ileo-ccecal  valve.  They  consist  in  a  more  or  less 
intense  redness  of  the  mucous  membrane,  which  sometimes  appears 


388         MORBID  APPEARANCES  IN  INFANTILE  DYSENTERY. 

thickened,  and  presents  something  of  a  velvety  appearance,  studded 
over  with  numerous  dark  spots — the  orifices  of  the  solitary  glands. 
In  other  instances,  the  surface  of  the  reddened  mucous  membrane 
appears  slightly  roughened,  as  if  sprinkled  over  with  fine  sand  ;  while 
near  to  the  caecum  this  roughening  is  often  greater,  the  membrane 
appearing  elevated  into  rough,  orange-coloured  prominences,  separated 
by  narrow  lines  of  a  dead  white  colour,  which  marks  the  situations 
where,  by  the  destruction  of  the  mucous  membrane,  the  subjacent 
tissue  is  exposed.  Both  of  these  changes  are  well  represented  in  this 
drawing  of  the  intestine  of  an  infant  six  months  old,  who  died  of  a 
relapse  of  diarrhoea,  from  which  she  had  seemed  to  be  in  course  of  reco- 
very. Besides  this  affection  of  the  mucous  membrane  of  the  ileum, 
Peyer's  glands  are  not  unfrequently  very  well  marked  in  the  lower  part 
of  the  small  intestine ;  and  their  surface  presents  a  punctuated  appear- 
rance,  due  to  the  unusual  distinctness  of  the  orifices. of  the  sacculi 
whieh  compose  each  gland.  Occasionally  a  few  of  them  are  congested 
and  swollen ;  and  once  or  twice  I  have  observed  one  or  two  spots  of 
ulceration  on  that  cluster  of  Peyer's  glands  which  is  situated  close  to 
the  ileo-coecal  valve ;  but  in  every  instance,  the  affection  of  the  small 
intestine  has  appeared  to  be  secondary,  and  quite  subsidiary,  to  the 
disease  in  the  colon.  Lastly,  I  may  observe,  that  the  mesenteric 
glands,  even  in  the  vicinity  of  the  diseased  large  intestine,  deviate  but 
little  from  a  state  of  health,  being  at  most  a  little  larger,  and  of  a 
somewhat  redder  colour,  than  usual — a  condition  which  contrasts 
remarkably  with  their  serious  affection  in  cases  of  typhoid  fever  in 
childhood,  while  yet  the  intestinal  lesion  is  often  much  less  considerable. 
The  symptoms  of  inflammatory  diarrhwa  sometimes  become  deve- 
loped very  gradually  out  of  what  had  seemed  at  first  to  be  nothing 
more  than  a  simple  looseness  of  the  bowels ;  but,  in  the  majority  of 
cases,  they  present,  almost  from  the  outset,  a  graver  character  than 
those  of  simple  diarrhoea,  and  are  associated  with  more  serious  consti- 
tutional disturbance.  When  the  attack  comes  on  suddenly,  it  often 
commences  with  vomiting ;  and  though  in  many  instances  the  sickness 
does  not  recur  frequently,  yet  sometimes  the  irritability  of  the  stomach 
continues,  for  twenty-four  or  forty-eight  hours,  to  be  so  extreme,  that 
every  drop  of  fluid  taken  is  immediately  rejected ;  and  that  frequent 
efforts  at  vomiting  are  made  even  when  the  stomach  is  empty.  Violent 
relaxation  of  the  bowels  occurs  almost  simultaneously  with  the  vomit- 
ing ;  and  the  child  sometimes  has  as  many  as  twenty  or  thirty  evacu- 
ations, or  even  more,  in  the  course  of  twenty-four  hours.  The  motions 
are  at  first  faecal ;  but  they  soon  lose  their  natural  character,  and 
become  intermixed  with  slime,  often  streaked  with  blood.  At  first 
they  are  abundant,  and  are  often  expelled  with  violence ;  but  before 
long  they  become  scanty,  though  sometimes  they  still  gush  out  without 
much  effort  on  the  part  of  the  child.  The  character  of  the  evacuations 
again  changes  :  in  the  severest  cases  they  not  only  lose  their  fgecal 
appearance,  but  become  like  dirty-green  water,  with  which  neither 
blood  nor  intestinal  mucus  is  intermingled.  Usually,  however,  when 
the  first  violence  of  the  purging  has  a  little  abated,  although  some 
serious  stools  may  still  be  voided,  yet  the  evacuations  consist  chiefly  of 


SYMPTOMS   OP   THE   AFFECTION.  389 

intestinal  mucus,  intermixed  with  a  little  feces,  and  more  or  less 
streaked  with  blood.  These  scanty  mucous  stools  are  generally  expelled 
with  much  straining  and  difficulty ;  a  few  drops  of  blood  sometimes 
follow  them  ;  and  once  or  twice,  at  an  early  period  of  the  attack,  I 
have  known  an  infant  void  as  much  as  a  table-spoonful  of  pure  blood. 

The  constitutional  symptoms  which  accompany  an  attack  of  this 
description  are  usually  very  severe  :  the  skin  becomes  dry  and  very 
hot,  though  unequally  so ;  the  pulse  is  quickened,  often  very  much  so  ; 
the  head  is  heavy  ;  the  child  fretful  and  irritable  if  disturbed,  though 
otherwise  it  lies  drowsily  in  its  nurse's  lap,  with  its  eyes  half  open,  and 
scarcely  closing  the  lids  even  when  they  are  touched  with  the  finger. 
Now  and  then,  too,  the  disturbance  of  the  nervous  system  at  the  com- 
mencement of  one  of  these  attacks  of  diarrhoea  is  so  considerable,  that 
a  state  of  excitement  alternates  with  one  of  stupor,  that  convulsions 
seem  impending,  and  that  there  are  distinct  carpo-pedal  contractions, 
or  startings  of  the  tendons  of  the  wrist  or  fore-arm.  The  abdomen  is 
usually  full,  and  rather  tympanitic,  but  seldom  very  tender ;  nor  does 
the  child  seem  to  suffer  much  pain,  though  sometimes  a  degree  of  tor- 
mina appears  to  precede  each  action  of  the  bowels.  The  tongue  at 
first  is  moist,  coated  slightly  with  mucous  fur  ;  its  papillae  are  often  of 
a  bright  red,  as  are  also  its  tip  and  edges ;  while,  if  the  disease  con- 
tinue, the  redness  becomes  more  general,  and  the  tongue  grows  dry, 
though  it  is  not  often  much  coated.  The  thirst  is  generally  intense, 
the  child  craving  for  cold  water,  and  crying  out  for  more  the  moment 
that  the  cup  is  taken  from  its  lips ;  and  the  thirst  is  quite  as  urgent 
even  in  those  cases  where  the  stomach  is  so  irritable  that  it  immedi- 
ately rejects  whatever  is  swallowed. 

There  is  scarcely  any  affection  in  which  the  loss  of  health  and  of 
flesh  is  so  rapid  as  in  the  severer  forms  of  diarrhoea  ;  and  a  period  of 
twenty-four  hours  will  in  some  cases  suffice  to  reduce  a  previously 
healthy  infant  to  a  condition  in  which  its  eyes  are  sunken,  its  features 
sharp,  its  limbs  shrunken,  and  its  strength  so  impaired,  that,  though  I 
have  never  seen  an  instance  of  it  myself,  I  can  yet  well  understand 
that  death  may  sometimes  take  place  in  the  course  of  a  few  hours  from 
the  commencement  of  the  attack.  This  rapidly  fatal  termination  is 
far  from  unusual  in  some  of  the  Southern  States  of  America,  where 
diarrhoea,  under  the  various  names  of  Cholera  Infantum,  the  Summer 
Complaint,  or  Gastro-follicular  Enteritis,  annually  destroys  many  thou- 
sands of  children. 

A  rapidly  fatal  termination,  however,  is  not  that  which  is  in  general 
observed  in  this  country  ;  but,  how  urgent  soever  the  symptoms  may 
have  been,  there  is  in  most  instances  a  spontaneous  subsidence  of  them 
in  the  course  of  forty-eight  hours  at  furthest ;  or  a  measure  of  abate- 
ment of  their  severity  follows  the  use  of  remedies.  The  sickness 
entirely  ceases  ;  the  bowels  act  much  less  frequently,  probably  not 
above  ten  or  twelve  times  in  the  twenty-four  hours  ;  but  they  act  irre- 
gularly, five  or  six  evacuations  being  passed  within  an  hour  or  two,  and 
then  no  action  of  the  bowels  occurring  for  four  or  five  hours  together. 
The  appearance  of  the  motions  likewise  varies,  and  apparently  without 
cause,  being  mucous,  green,  watery,  intermingled  with  blood,  all  in 


390  OF   ITS   CHRONIC    STAGE. 

the  course  of  a  single  clay,  and  with  no  accompanying  modification  in, 
the  infant's  symptoms.  The  tenesmus  in  general  continues ;  and  in 
weakly  children,  or  in  those  who  have  previously  suffered  from  diarrhoea, 
prolapsus  ani  not  infrequently  occurs  ;  though  this  accident  happens 
less  commonly  in  infants  than  in  children  of  two  or  three  years  old. 

There  is  much  uncertainty  in  the  further  course  of  the  affection,  and 
in  the  way  in  which  it  tends  in  one  instance  towards  recovery,  and  in 
another  to  a  fatal  issue.  Many  fluctuations  generally  interrupt  the 
progress  of  those  cases  which  terminate  favourably  ;  while,  when  it 
eventually  proves  fatal,  the  affection  often  assumes  a  chronic  character, 
and  does  not  end  in  death  until  after  the  lapse  of  several  weeks. 

In  such  chronic  cases,  the  patient's  condition,  through  progressively 
tending  from  bad  to  worse,  presents  but  little  difference  from  day  to 
day.  The  loss  of  flesh  goes  on  until  the  child  is  reduced  to  a  degree  of 
emaciation  as  great  as  is  ever  witnessed  even  in  the  most  advanced 
stage  of  mesenteric  disease  or  pulmonary  consumption,  though  its 
extreme  attenuation  is  sometimes  concealed  by  the  anasarcous  swelling 
of  its  face  and  hands.  The  appetite  fails  completely,  or  becomes  very 
capricious  ;  and  the  child  refuses  to-day  the  food  which  yesterday  it 
took  with  eagerness.  In  course  of  time,  the  desire  for  drink  is  lost 
too  ;  for  though  there  may  be  no  return  of  vomiting,  yet  nausea  is 
excited  by  everything  which  the  child  takes.  The  tongue  grows  red 
and  dry,  coated  with  brown  or  yellow  fur  towards  its  root,  or  aphthae 
appears  upon  its  tip  and  edges,  or  the  whole  inside  of  the  mouth 
becomes  coated  with  muguet.  The  diarrhoea  continues  much  as  it  was 
before,  except  that  the  action  of  the  bowels  is  now  almost  immediately 
excited  by  either  food  or  drink.  The  evacuations  are  usually  of  a 
green  colour,  ?often  particoloured,  and  though  generally  watery,  yet 
they  vary  both  in  their  consistence  and  in  their  other  characters,  with- 
out apparent  cause.  Slime,  blood,  and  pus,  are  sometimes  present  in 
the  stools,  at  other  times  absent ;  and  it  does  not  often  happen  that 
purulent  matter  is  present  in  large  quantity  in  the  evacuations,  or  for 
many  days  together,  though  I  have  observed  this  in  some  cases  that 
recovered,  as  well  as  in  others  which  had  a  fatal  termination.  The 
body  is  no  longer  able  to  maintain  its  proper  temperature,  but  the 
extremities  are  almost  invariably  cold ;  small  indolent  abscesses  occa- 
sionally form  about  the  buttocks  ;  and  on  one  occasion  I  saw  an  erup- 
tion of  large  vesicles,  like  those  of  pemphigus,  make  their  appearance 
on  the  hands,  arms,  and  neck  of  an  infant  eight  months  old,  about  ten 
days  before  her  death.  In  the  condition  of  weakness  to  which  the 
child  is  now  reduced,  a  slight  aggravation  of  the  diarrhoea,  or  a  return 
of  vomiting,  suffices  to  put  out  its  feeble  life  ;  or,  even  should  no  such 
accident  occur,  death  takes  place  from  pure  exhaustion. 

But  various  causes  may  abridge  this  protracted  course  of  the  affec- 
tion ;  and  hence  it  results  that  death  not  infrequently  takes  place  before 
the  mischief  in  the  intestines  has  become  so  serious  as  it  is  usually 
found  to  be  in  cases  of  fatal  dysentery  in  the  adult.  Bronchitis  is  one 
of  the  most  frequent  of  these  intercurrent  maladies,  while  the  symp- 
toms that  attend  it  are  often  so  slight,  that  danger  to  the  patient  from 
this  source  is  very  frequently  overlooked.    It  happens,  indeed,  in  many 


VARIOUS  CAUSES  OF  DEATH.  391 

cases,  that  almost  from  the  outset  of  an  attack  of  diarrhoea,  the  mucous 
membrane  of  the  respiratory  organs  sympathises  with  the  irritation  of 
the  intestinal  canal,  and  from  the  very  commencement  of  its  illness  the 
child  has  slight  cough,  the  continuance  or  even  the  aggravation  of 
which  attracts  but  little  notice.  Unless,  therefore,  auscultation  is 
carefully  practised,  and  often  repeated,  there  is  little  in  such  cases  to 
call  attention  to  the  state  of  the  respiratory  organs  until  the  accu- 
mulated secretions  in  the  bronchi  have  already  seriously  interfered 
with  the  entrance  of  air  into  the  pulmonary  vesicles,  and  have 
occasioned  the  collapse  of  a  considerable  extent  of  the  substance  of 
the  lungs. 

Life  is  sometimes  cut  short  by  other  causes  in  the  course  of  infantile 
diarrhoea.  The  disturbance  of  the  nervous  system  that  attends  the 
attack  issues  now  and  then  in  convulsions,  and  these  convulsions  end  in 
a  state  of  stupor  which  terminates  in  death — an  occurrence  fortunately 
rare,  but  of  which  instances  may  be  observed  during  those  hot  seasons 
of  the  year  when  bowel  complaints  are  usually  epidemic.  Less  rare 
than  a  fatal  termination  of  this  kind  is  the  infant's  death  under  symp- 
toms of  a  gradually  deepening  coma,  which  may  have  supervened  on 
the  suppression  of  the  diarrhoea,  or  on  its  great  mitigation.  Many  of 
the  symptoms  by  which  this  condition  is  accompanied  are  such  as  to 
indicate  the  exhaustion  of  the  infant's  powers  ;  but  it  happens  in  many 
instances  that  there  is  an  occasional  flush  of  the  face,  or  a  temporary 
heat  of  skin,  or  some  other  passing  sign  of  an  attempt  at  reaction,  just 
sufficient  to  mislead  the  practitioner,  and  to  betray  him  into  a  vacil- 
lating line  of  practice  that  proves  fatal  to  his  patient. 

Lastly,  the^e  are  cases,  and  those  by  no  means  few,  in  which  the 
onset  of  a  severe  attack  of  diarrhoea  has  been  promptly  met  and  judi- 
ciously treated,  in  which  the  symptoms  have  yielded,  and  the  child  has 
appeared  convalescent.  Some  slight  error  in  diet,  however,  a  variation 
in  the  temperature,  or  the  too  early  withdrawal  of  medicine,  is  followed 
by  a  return  of  the  vomiting  and  purging  ;  or  the  relapse  may  take  place 
without  our  being  able  to  assign  for  it  any  adequate  cause.  The  active 
symptoms  which  attended  the  original  seizure  are  absent  now;  the 
evacuations,  though  very  watery,  generally  contain  neither  blood  nor 
slime;  but  medicine  is  often  wholly  unable  to  check  them.  The  vital 
powers  fail  speedily,  and  death  often  takes  place  in  three  or  four  days 
from  this  exacerbation  of  the  symptoms  ;  while  an  examination  of  the 
body  after  death  shows  no  evidence  of  recent  mischief  in  the  intestines, 
but  only  the  traces  left  by  the  first  attack,  and  these  manifestly  in 
course  of  disappearance. 

We  must  postpone  until  the  next  lecture  the  very  important  subject 
of  the  treatment  appropriate  to  all  the  varieties  of  diarrhoea  and  its 
different  complications. 


392  DIARaH(EA  CONTINUED. 


LECTURE    XXXIII. 

Diaerh(ea,  continued. — Close  resemblance  between  inflammatory  diarrhoea  and  tbe 
dysentery  of  the  adult — local  conditions  favouring  its  occurrence,  as  damp,  want  of 
drainage,  &c. 

Treatment  of  simple  diarrhoea — of  diarrhoea  in  connection  with  teething — use  of  astrin- 
gents. 

Treatment  of  inflammatory  diarrhoea — in  its  acute  stage — treatment  of  certain  symptoms 
— as  the  irritability  of  the  stomach,  the  cerebral  symptoms — indications  for  the  use 
of  stimulants — of  astringents — management  of  the  chronic  stage — use  of  enemata — 
diet  in  this  stage. 

Management  of  intertrigo  excited  by  diarrhoea — and  of  prolapsus  ani. 

Those  of  you  who  were  present  at  yesterday's  lecture  could  hardly 
fail  to  be  struck  by  the  close  resemblance  which  exists  between  the 
severer  forms  of  infantile  diarrhoea  and  the  true  dysentery  of  the  adult. 
In  both  cases  similar  morbid  appearances  are  discovered,  occupying  the 
same  parts  of  the  intestinal  canal ;  in  both  the  symptoms  during  life 
are  almost  identical,  their  resemblance  being  disturbed  mainly  by  the 
greater  excitability  of  the  nervous  system  in  early  life;  whence  it 
arises  that  convulsions  and  other  signs  of  serious  cerebral  disturbance 
are  often  observed  in  the  infant  affected  with  diarrhoea,  while  they  are 
but  seldom  noticed  in  the  adult  suffering  even  from  severe  dysentery. 
But  this  difference  is  one  of  degree  rather  than  of  kind,  since  the 
morbid  poison,  whateverbe  its  nature,  to  which  dvsentery  is  due  in  the 
adult,  produces  under  favourable  circumstances  disorders  of  the  nervous 
system  analogous  to  those  which  we  may  have  frequent  opportunities 
of  observing  in  the  infant.  If  dysentery,  for  instance,  break  out  epi- 
demically in  a  large  prison,  the  inmates  of  which  have  had  the  excita- 
bility of  their  nervous  system  increased  by  the  debilitating  influence  of 
long  confinement,  tremors,  cramps,  spasms,  convulsions  or  stupor,  may 
attend  upon  the  affection,  and  death  may  take  place  under  symptoms 
that  betoken  disorder  of  the  brain  or  spinal  cord.  You  will  find  ample 
proof  of  this  in  Dr.  Latham's  account  of  the  Disease  at  the  Peniten- 
tiary in  the  year  1823  ;  and  in  Dr.  Baly's  Gulstonian  Lectures  on 
Dysentery,  which  are  based  on  observations  at  the  same  establishment. 
Among  the  striking  examples  of  this  complication  related  by  those 
writers,  some  are  recorded  in  which,  though  death  took  place,  neither 
the  brain  nor  the  spinal  cord  presented  any  sign  of  disease.  Just  of 
the  same  kind,  and  equally  independent  of  any  appreciable  change  of 
structure,  are  the  nervous  symptoms  that  often  come  on  in  the  course 
of  infantile  diarrhoea.  I  shall  have  presently  to  refer  to  the  important 
practical  bearings  of  this  fact,  when  we  come  to  consider  the  treatment 
of  diarrhoea  and  its  complications. 

Before  we  pass  to  that  subject,  however,  we  must  inquire  whether 
there  are  any  special  conditions  that  tend  to  engender  the  severer  forms 
of  bowel  complaint  in  childhood,  over  and  above  those  general  causes  of 
diarrhoea  to  which  your  attention  was  directed  in  the  last  lecture.     I 


INFANTILE   DYSENTERY   INDEPENDENT   OF   LOCAL   CAUSES.  393 

believe  that  such  special  conditions  do  exist — that  they  abound  in  the 
locality  where  most  of  my  observations  have  been  made — and  that  they 
are  precisely  the  same  as  prevailed  far  more  extensively  in  this  metro- 
polis at  the  time  that  the  bloody  flux  annually  carried  off  large  numbers 
of  its  inhabitants. 

In  almost  every  country  and  climate,  and  under  circumstances  in 
many  respects  very  different,  dysentery  has  been  known  to  occur,  but 
in  each  instance  it  has  been  possible  to  connect  the  prevalence  of  the 
disease  with  some  source  or  other  of  malaria.  Although,  while  I  was 
physician  to  the  Finsbury  Dispensary,  a  large  amount  of  disease  among 
children  as  well  as  among  adults  came  under  my  notice,  yet  my  acquaint- 
ance with  those  severer  forms  of  infantile  diarrhoea  which  approach  to 
the  characters  of  dysentery,  and  which  give  rise  to  similar  lesions,  has 
been  derived  almost  exclusively  from  observations  made  in  Lambeth  and 
the  adjoining  parishes.  The  children  in  both  districts  are  alike  sub- 
jected to  the  evils  of  improper  and  insufficient  food,  and  of  close  and 
ill-ventilated  dwellings;  but  in  the  latter  there  are  superadded  certain 
very  important  influences  of  a  local  character.  A  considerable  portion 
of  the  district  on  the  Surrey  side  of  the  Thames  lies  below  high-water 
mark  ;  and  the  kitchens  and  cellars  of  some  of  the  houses  near  the  river 
become  flooded  at  unusually  high  tides.  The  sewerage  throughout  is 
very  defective  ;  in  many  parts  it  is  effected  entirely  by  open  drains, 
while  in  some  places  there  are  mere  cesspools,  which  have  no  communi- 
cation with  any  drain  whatever.  Cases  of  infantile  dysentery  do  not 
occur  with  the  same  frequency  in  all  parts  of  this  district,  but  they  are 
most  numerous  and  most  severe  wherever  these  noxious  influences  are 
most  abundant.  Proof,  too,  of  the  intimate  connection  that  subsists 
between  these  conditions  and  the  occurrence  of  infantile  dysentery  is 
afforded  by  cases  such  as  the  following : — 

With  the  return  of  every  spring,  a  poor  woman  brought  to  me  her 
younger  children  suffering  from  diarrhoea,  which  they  seemed  to  outgrow 
when  about  three  years  old.  This  diarrhoea  was  always  obstinate,  very 
apt  to  assume  a  dysenteric  character,  and  was  almost  sure  to  return  if 
medicines  were  discontinued  before  the  return  of  the  cold  season.  On 
one  occasion,  her  infant,  aged  about  fifteen  months,  who  had  had  diar- 
rhoea severely  in  the  previous  autumn,  suffered  a  return  of  it  with  the 
returning  warmth  of  spring.  The  infant's  symptoms  were  very  alarming, 
and  the  child  had  frequent  convulsions;  on  which  account  I  visited  her 
at  home.  I  then  found  that  the  infant  spent  the  whole  of  the  day  in  a 
back  room  on  the  ground  floor  which  looked  out  upon  a  little  yard,  at 
the  bottom  of  which  there  was  a  large  cesspool,  whence  there  came  a 
most  offensive  smell  during  the  whole  of  the  warm  weather.  I  urged 
the  mother  to  remove  her  infant  from  this  room,  and  to  occupy  instead 
a  front  room  on  the  first  floor  in  the  same  house,  which  looked  upon  the 
street.  When  this  had  been  done,  the  convulsions  ceased  almost  at 
once,  and  the  diarrhoea  was  not  long  before  it  disappeared.  I  have 
attended  this  woman's  children  since  for  other  affections,  but  they  have 
now  for  nearly  eighteen  months  occupied  the  more  wholesome  room, 
and  during  this  time  I  have  heard  nothing  of  their  suffering  from  diar- 
rhoea.    I  may  just  add,  that  under  similar  circumstances,  I  have  met 


894  MALARIA   A   CAUSE   OF   DYSENTERY. 

with  a  few  instances  of  the  sudden  and  apparently  causeless  occurrence 
of  convulsions,  in  two  or  three  children  of  the  same  family.  It  is  not 
long  since  a  little  girl,  five  years  old,  was  seized  with  convulsions,  which 
recurred  frequently  for  between  two  and  three  days,  leaving  her  in  a 
state  of  stupor.  By  degrees  the  symptoms  of  very  severe  typhoid  fever 
developed  themselves  out  of  this  disturbance  of  the  nervous  system. 
The  disease  during  the  whole  of  its  course  presented  an  adynamic  cha- 
racter, and  required  the  free  employment  of  wine  and  stimulants. 
While  she  was  convalescent,  the  health  of  her  elder  sister,  who  was 
eight  years  old,  began  to  fail,  and  before  long  she  experienced  convul- 
sive attacks  of  an  anomalous  character  not  unlike  fits  of  hysteria,  which 
returned  at  intervals  of  two  or  three  days  for  several  weeks  together, 
three  or  four  fits  sometimes  occurring  in  the  course  of  a  single  day. 
These  seizures  were  accompanied  with  much  debility,  and  they  disap- 
peared by  degrees  under  the  use  of  preparations  of  iron,  and  a  generally 
tonic  plan  of  treatment. 

In  studying  the  treatment  of  diarrhoea  and  dysentery  in  early  life,  we 
will  pass  successively  in  review  the  different  forms  of  the  disease  ;  begin- 
ning with  the  simplest  and  least  dangerous,  and  passing  to  the  more 
formidable  varieties  of  the  affection,  and  to  those  complications  which 
add  so  greatly  to  its  hazard. 

In  a  large  proportion  of  cases  of  simple  infantile  diarrhoea,  the 
ailment  tends  to  subside  in  a  day  or  two,  and  finally  to  cease  of  its  own 
accord.  While, -therefore,  in  consideration  of  the  tender  years  of  the 
patient,  no  such  case  can  be  regarded  as  altogether  trivial,  yet  in  many 
instances  but  little  medical  interference  is  needed.  Great  care,  how- 
ever is  required  in  this,  as  well  as  in  the  more  serious  forms  of  diarrhoea, 
to  prevent  the  affection  being  aggravated  by  any  error  of  diet,  or  even 
by  the  infant  being  allowed  to  partake  too  freely  of  food  otherwise  suit- 
able for  it.  If,  therefore,  the  sickness  with  which  the  attack  sets  in 
have  not  altogether  subsided,  the  child  should  be  taken  completely  from 
the  breast  for  a  few  hours,  and  should  have  nothing  more  than  a  few 
spoonfuls  of  water  or  barley-water,  till  the  irritability  of  the  stomach 
has  abated.  If  the  disposition  to  vomit  have  completely  ceased,  it  will 
yet  be  right  to  put  the  infant  less  frequently  to  the  breast ;  while  it  is 
supplied,  if  thirsty,  with  water,  or  barley-water,  in  small  quantities  at  a 
time.  In  children  already  weaned,  a  similar  plan  must  be  carried  out ; 
solid  food  being  for  a  time  withdrawn,  and  thin  arrow-root,  or  barley- 
water  and  milk,  in  equal  parts,  being  substituted  for  it.  If  the  attack 
be  clearly  traceable  to  some  improper  article  of  food,  a  dose  of  castor- 
oil  will  sometimes  get  rid  of  the  irritant  cause  and  of  the  diarrhoea 
together.  Unless  this  be  the  case,  however,  it  is  better  not  to  give  the 
aperient,  since  its  action,  under  these  circumstances,  is  somewhat  uncer- 
tain ;  and  instead  of  relieving,  it  may  aggravate  the  diarrhoea.  Provided 
there  be  neither  much  pain  nor  much  tenesmus,  and  the  evacuations, 
though  watery,  are  faecal,  and  contain  little  mucus  and  no  blood,  very 
small  doses  of  the  sulphate  of  magnesia  and  tincture  of  rhubarb  have 
seemed  to  me  more  useful  than  any  other  remedy  j1  and  I  seldom  fail 

1  See  Formula,  No.  26,  p.  3G4. 


TREATMENT   OF   SIMPLE   DIARRHOEA.  395 

to  observe  from  it  a  speedy  diminution  in  the  frequency  of  the  action 
of  the  bowels,  and  a  return  of  the  natural  character  of  the  evacuations. 

In  the  diarrhoea  that  comes  on  in  connection  with  teething ',  it  has 
seemed  to  be  better  to  pursue  a  somewhat  different  plan.  It  is  usually 
attended  by  a  greater  amount  of  constitutional  disturbance  than  is 
observed  in  the  diarrhoea  of  younger  infants,  and  by  some  degree  of 
febrile  excitement.  There  is  likewise,  in  many  instances,  a  considerable 
disposition  to  catarrhal  affection  of  the  respiratory  mucous  membrane, 
which  needs  to  be  carefully  watched,  lest  by  its  increase  it  should 
become  a  source  of  serious  danger  to  the  child.  The  diarrhoea  in  the 
majority  of  these  cases  comes  on  gradually,  and  its  subsidence  takes 
place  gradually  too.  Now  and  then  the  gum  may  appear  at  one  spot 
so  tense  and  swollen,  as  to  induce  us  to  scarify  it ;  and  if  the  tooth  be 
very  near  the  surface,  this  proceeding  may  sometimes  greatly  diminish 
the  diarrhoea,  by  relieving  the  irritation  which  excited  it.  Any  such 
marked  benefit,  however,  is  quite  an  exceptionable  occurrence ;  and 
unless  the  state  of  the  gums  be  such  as  of  itself  to  indicate  the  pro- 
priety of  scarifying  them,  it  would  be  a  cruel  and  useless  piece  of 
empiricism  to  subject  the  child  to  the  distress  of  the  operation.  Instead 
of  the  saline  and  rhubarb  mixture  wThich  I  have  just  mentioned,  I  usually 
employ  in  these  cases  small  doses  of  ipecacuanha  in  combination  with 
an  alkali ;  and  think  that  I  have  found  great  benefit  from  this  plan. 
Three  or  four  drops  of  liquor  potassas,  and  the  same  quantity  of  vinum 
ipecacuanha,  mixed  with  mucilage,1  and  given  in  a  little  milk  about 
every  four  hours,  is  a  suitable  dose  for  an  infant  a  twelvemonth  old. 
At  the  same  time  the  child  should  be  placed  in  a  tepid  bath  every  night ; 
and  a  powder\of  one  grain  of  Dover's  powder,  and  one  of  mercury  with 
chalk,  given  to  it  afterwards,  will  often  be  found  to  procure  for  the  little 
patient,  previously  restless  and  fretful,  some  hours  of  quiet  repose.  If 
the  child  should  appear  much  exhausted,  a  slight  stimulant,  such  as  four 
or  five  drops  of  the  spirit  of  nitrous  ether,  may  be  advantageously  com- 
bined with  each  dose  of  the  mixture  ;  and  in  all  cases  of  simple  diarrhoea 
it  behoves  us  to  watch  most  carefully  against  the  powers  becoming  too 
much  depressed,  either  by  the  profuseness  of  the  purging  or  by  its  con- 
tinuance. 

Supposing  in  any  case  that  a  considerable  degree  of  looseness  of  the 
bowels  should  continue  after  the  lapse  of  two  or  three  days,  astringents 
must  be  resorted  to ;  and  I  know  of  none  better  than  the  extract  of 
ogwood,  in  combination  with  tincture    of    catechu2.      The   logwood 

(No.  27.) 
2  R  Extr.  Hsematoxyli,  gj. 
Tinct.  Catechu,  gij. 
Syrupi,  gj. 

Aquae  Carui.  gix.     M.     gj.  ter  die. 
For  a  child  a  year  old. 

moreover,  is  something  besides  a  mere  astringent ;  it  is  a  very  valuable 
tonic  in  all  cases  where  gastro-intestinal  disorder  has  existed  ;  and  it  is 
one  which  children  take  readily.  It  is,  however,  not  very  popular  in 
the  nursery,  because  it  imparts  to  the  evacuations  a  deep  pink  colour, 
1  See  Formula  No.  21,  p.  843. 


396  OF   INFLAMMATORY   DIARRHOEA. 

"which  leaves  an  indelible  stain  upon  the  napkins:  a  circumstance  which 
it  is  as  well  to  mention  when  you  prescribe  the  medicine.  The  mercury 
and  chalk  and  Dover's  powder  may  be  still  continued  at  bed-time,  if 
the  evacuations,  though  less  frequent,  be  still  slimy  and  unhealthy.  If 
either  the  evacuations  or  the  infant's  breath  have  a  sour  smell,  three 
grains  of  the  sesquicarbonate  of  soda  may  be  added  to  each  dose  of  the 
mixture ;  or,  if  the  child  be  not  wholly  fed  at  the  breast,  a  drachm  of 
prepared  chalk  may  be  stirred  up  with  each  pint  of  milk  given  to  it ; 
and  after  the  powder  has  been  allowed  to  settle,  enough  will  still  remain 
suspended  in  the  fluid  to  counteract  any  slight  acidity  in  the  alimentary 
canal.  If,  after  the  bowels  have  become  quite  regular,  some  tonic  should 
still  be  required,  the  extract  of  bark,  with  small  doses  of  the  tincture,1 
will  be  onerof  the.  best  that  can  be  given.  You  will  observe  that  all 
the  remedies  mentioned  occupy  but  a  very  small  compass, — a  point  the 
importance  of  which  is  never  to  be  forgotten  in  prescribing  for  children. 

But  there  are  cases  which  wear  a  much  more  serious  aspect  than  those 
the  treatment  of  which  we  have  hitherto  considered.  Even  in  true 
inflammatory  diarrhma,  however,  depletion  is  but  seldom  needed ;  for 
either  the  abdominal  tenderness  is  inconsiderable,  or,  if  the  attack  set 
in  with  great  severity,  it  will  be  generally  found  to  have  occasioned  so 
much  depression  as  to  contra-indicate  the  abstraction  of  blood.  Still, 
in  cases  of  recent  date,  if  the  abdominal  tenderness  be  considerable,  and 
if  it  be  associated  with  much  heat  of  skin  and  febrile  disturbance,  a  few 
leeches  may  be  applied  in  either  iliac  region.  The  child  should  be  care- 
fully watched  for  some  hours  afterwards,  in  order  to  prevent  any  exces- 
sive loss  of  blood ;  since  considerable  haemorrhage  not  unfrequently 
follows  the  application  of  leeches  to  the  abdomen,  and  it  is  not  always 
very  easily  arrested.  On  this  account,  I  think  you  may  find  it  the 
better  plan  to  apply  the  leeches  to  the  margin  of  the  anus,  in  which 
situation  they  will  relieve  the  bowels  at  least  as  much,  while  the  bleed- 
ing from  them  will  be  completely  under  your  control.  In  the  majority 
of  instances  the  pain  and  tenderness  of  the  abdomen  are  much  relieved 
by  the  application  of  a  large  hot  bran  poultice;  the  frequent  renewal  of 
which  often  affords  great  comfort  to  the  child. 

If  the  irritability  of  the  stomach  be  not  so  great  as  to  prevent  its 
administration,  no  medicine  is  of  such  general  application,  or  of  such 
essential  service,  in  these  cases,  as  a  mixture  containing  a  small  quantity 
of  castor  oil  diffused  in  mucilage,  with  the  addition  of  a  few  drops  of 
tincture  of  opium  ;  which  I  was  led  to  use  in  the  inflammatory  diarrhcea 
of  children  from  observing  the  great  benefit  which  followed  its  employ- 
ment by  my  friend  Dr.  Baly,  in  the  treatment  of  dysentery  among  the 
prisoners  in  Milbank  Penitentiary.3 

(No.  28.) 
2  R  01.  Bicini,  3J. 
Pulv.  Acacise,  £ss. 
Sacchari,  albi,  %ss. 
Tinct.  Opii,  TT^iv. 
Aquae  Flor.  Aurant.  gvij.     M.     3J.  4tis  horis. 

For  a  child  a  year  old. 
1  See  Formula  No.  3,  p.  45. 


TREATMENT   OF   THE   NERVOUS    SYMPTOMS.  397 

Although  this  medicine  may  relieve  all  the  symptoms  considerably, 
and  although  the  general  state  of  the  child  may  be  much  improved,  yet 
it  sometimes  happens  that  a  considerable  degree  both  of  tenesmus  and 
of  purging  continue.  These  symptoms  will  now  be  more  effectually 
relieved  by  an  opiate  enema  than  by  any  other  means.  Three  minims 
of  laudanum  will  form,  an  enema  of  sufficient  strength  for  an  infant  a 
year  old ;  and  this  should  be  given  suspended  in  half  an  ounce  of  muci- 
lage, since  a  more  bulky  injection  is  almost  sure  to  be  immediately 
expelled.  Supposing  the  symptoms  not  to  yield  to  these  means,  or  that 
the  case  presented  from  the  first  a  great  degree  of  severity,  small  doses 
of  Hyd.  c.  Creta,  and  Dover's  powder  may  be  given  every  four  hours, 
in  addition  to  the  castor  oil  mixture;  which,  however,  should  now  be 
given  without  the  laudanum. 

In  some  cases  the  irritability  of  the  stomach  is  so  great,  that  almost 
every  thing  taken  is  speedily  rejected;  and  when  this  condition  is 
present,  none  of  the  medicines  already  mentioned  can  be  borne.  Under 
these  circumstances  a  small  mustard  poultice  should  at  once  be  applied 
to  the  epigastrium,  the  child  should  be  taken  from  the  breast,  a  tea- 
spoonful  of  cold  water,  or  cold  barley-water,  should  be  given  at  inter- 
vals, and  a  powder  of  a  third  of  a  grain  of  calomel,  and  a  twelfth  of  a 
grain  of  opium,  should  be  laid  upon  its  tongue  every  three  hours.  The 
sickness  will  generally  subside  in  four  or  five  hours,  though  the  stomach 
often  remains  too  irritable  to  bear  any  change  in  the  remedies,  and  the 
greatest  caution  will  be  needed  in  restoring  the  infant  to  the  breast. 
It  may  be  necessary,  indeed,  to  confine  the  child  for  twenty-four  or 
thirty-six  hours  to  cold  barley-water,  cold  water  thickened  with  isinglass, 
the  white  decoction  of  Sydenham,  or  equal  parts  of  cold  milk  and  water ; 
and  when  the \mild  has  been  seen  early  in  the  disease,  I  have  never 
observed  any  evil  to  follow  the  perseverance  for  this  short  period  in  a 
rigorous  diet. 

The  tepid  bath  employed  twice  a  day,  or  even  more  frequently,  will 
be  found  of  great  service  in  soothing  that  general  irritability  of  the 
nervous  system  which  often  continues  through  the  whole  course  of  the 
affection,  and  which  sometimes  issues  in  convulsive  seizures,  or  in  other 
symptoms  that  are  occasionally  mistaken  for  the  indications  of  real  cere- 
bral disease.  It  cannot  be  necessary  to  reiterate  here  the  often- 
repeated  caution  against  regarding  the  symptoms  of  disturbance  of  the 
nervous  system  as  being  always  the  signs  of  active  cerebral  disorder, 
calling  for  depletion  to  relieve  the  congestion  of  the  vessels  of  the  brain, 
and  for  antiphlogistic  measures  to  moderate  the  excited  state  of  the 
circulation.  At  the  very  commencement  of  this  course  of  lectures1  I 
endeavoured  to  set  before  you  the  various  circumstances  under  which 
convulsions  came  on  in  early  life ;  and  some  days  ago2  I  tried  to  deli- 
neate the  characteristic  features  of  spurious  hydrocephalus.  On  that 
occasion  I  related  the  history  of  two  children,  both  of  whom  had  been 
attacked  by  severe  diarrhoea.  In  one  case,  the  child  passed  every  few 
minutes  from  a  state  of  listless  drowsiness  to  a  condition  of  extreme 
restlessness  and  alarm ;  the  tendons  of  the  forearm  were  in  a  state  of 

1  Lecture  II.  p.  31.  ,    2  Lecture  X.  p.  111. 


398  USE   OF    STIMULANTS. 

subsultus,  and  general  convulsions  seemed  impending.  In  the  other 
case,  the  irritability  of  the  nervous  system  was  rapidly  subsiding  under 
the  general  exhaustion  of  the  vital  powers,  and  probably  in  a  few  hours 
more  the  infant  would  have  sunk  into  a  profound  coma,  from  which  no 
means  would  have  been  adequate  to  rouse  it.  The  tepid  bath  and  an 
opiate  enema  in  the  first-mentioned  case,  and  the  free  employment  of 
stimulants  in  combination  with  small  doses  of  Dover's  powder  in  the 
second,  speedily  averted  dangers  that  had  seemed  so  threatening.  I 
need  not,  however,  tread  again  over  all  the  ground  wre  have  already 
passed,  but  will  content  myself  with  repeating  the  remark  I  then  made, 
— that  if,  in  cases  of  this  kind,  you  fall  into  the  error  of  regarding  the 
cerebral  symptoms  as  the  signs  of  active  disease,  and  withhold  the 
Dover's  powder  or  the  opiate  enema,  that  might  have  checked  the  diar- 
rhoea and  soothed  the  irritability,  while  you  apply  cold  lotions  to  the 
head,  and  give  the  child  nothing  more  nutritious  than  barley-water  in 
small  quantities,  because  the  irritability  of  the  stomach,  which  results 
from  weakness,  seems  to  you  to  be  the  indication  of  disease  of  the  brain, 
the  restlessness  will  before  long  alternate  with  coma,  and  the  child  will 
die  either  comatose  or  in  convulsions. 

As  to  the  time  when  stimulants  are  to  be  given,  or  the  quantity  in 
which  they  are  to  be  employed,  no  definite  rule  can  be  laid  down.  Each 
case  must  be  treated  for  itself;  and  to  be  treated  successfully  it  must 
be  watched  most  closely.  The  necessity  for  stimulants  may  arise  sud- 
denly, or  the  need  of  their  administration  may  be  but  temporary ;  while 
the  infant's  state  in  the  morning  affords,  in  cases  of  severe  diarrhoea, 
no  sure  criterion  by  wThich  to  judge  what  its  condition  will  be  at  night. 
In  general,  it  is  not  until  the  active  symptoms  have  begun  to  decline 
that  stimulants  are  needed,  nor  even  then  are  they  required  in  a  large 
number  of  instances.  I  have,  however,  met  with  some  instances  in 
which  they  were  absolutely  necessary  as  early  as  the  second  or  third 
day  of  the  disease.  This  has  occurred  in  cases  in  which  there  was 
great  irritability  of  the  stomach,  as  well  as  violent  action  of  the  bowels ; 
in  which  no  medicine  could  be  borne  except  the  calomel  and  opium 
powders,  nor  any  drinks  except  such  as  were  given  cold.  Under  such 
circumstances  a  state  of  extreme  debility  is  sometimes  very  rapidly 
induced,  and  the  vomiting,  wThich  at  first  was  a  sign  of  the  gastric  dis- 
order, continues,  when  it  is  nothing  else  than  an  effect  of  the  general 
exhaustion.  About  half  a  drachm  of  brandy  given  every  two  or  three 
hours  to  a  child  of  a  year  old,  in  a  quantity  of  a  few  drops  at  a  time, 
mixed  with  the  cold  milk  and  water,  or  the  thin  arrow-root  with  which 
it  is  fed,  will  often  have  the  effect  of  arresting  the  sickness,  as  well  as 
of  rallying  the  sunken  energies  of  the  system.  No  stimulant  has 
appeared  to  answer  the  required  ends  better  than  brandy :  and,  when 
sufficiently  diluted,  children  take  it  very  readily.  Sometimes,  however, 
when  it  has  been  necessary  to  continue  it  for  some  time,  it  has  seemed 
to  occasion  pain  in  the  stomach,  and  even  to  nauseate  the  child ;  and  in 
this  case  the  compound  tincture  of  bark,  or  the  aromatic  spirits  of 
ammonia,  or  the  two  together,  may  be  substituted  for  it;  and  there  is 
seldom  much  difficulty  in  administering  them,  if  they  be  mixed  with 
milk  and  sufficiently  sweetened. 


TREATMENT   OF   CHRONIC   DIARRHEA.  399 

The  proper  time  for  the  employment  of  aromatics  and  astringents  is 
not  during  the  acute  stage  of  the  affection :  but  when  the  disease  has 
already  begun  to  decline,  these  remedies  will  be  found  of  most  essential 
service  in  checking  that  looseness  of  the  bowels  which  otherwise  is  very 
apt  to  degenerate  into  a  state  of  chronic  diarrhoea.  Under  these  cir- 
cumstances the  logwood  and  catechu  mixture,  mentioned  at  an  early 
part  of  this  lecture,  is  a  very  valuable  medicine.  If,  notwithstanding 
its  employment,  the  bowels  still  continue  to  act  with  excessive  frequency, 
small  doses  of  the  compound  powTder  of  chalk  and  opium  may  be  given 
twice  a  day,1  or  the  use  of  the  opiate  enema  may  be  continued  if  there 

(No.  29.) 
\  R  Pulv.  Crete  Co.  c.  Opio,  ^j. 

Inf.  Catechu  Co.  3iss.     M.     gj.  bis  vel  ter  die. 
For  a  child  a  year  old. 

be  much  tenesmus.  By  these  means,  coupled  with  the  most  sedulous 
attention  to  the  child's  diet,  and  the  greatest  care  in  allowing  either 
animal  broths  or  meat  or  other  solid  food,  a  complete  cure  will  usually 
be  brought  about  in  the  course  of  two,  or  at  the  latest,  of  three  weeks. 
There  are  some  cases  in  which,  after  the  disease  has  passed  its  acute 
stage,  it  still  retains  much  of  its  dysenteric  character ;  the  bowels  not 
merely  acting  with  undue  frequency,  but  the  evacuations  containing 
mucus,  pus,  or  blood,  and  their  expulsion  being  attended  with  very  con- 
siderable tenesmus.  The  strength  in  such  chronic  cases  is  very  greatly 
reduced,  and  emaciation  goes  on  to  a  greater  degree  than  in  almost  any 
other  affection,  with  the  exception  of  phthisis  and  mesenteric  disease ; 
while  the  bowels  are  excited  to  almost  immediate  action  by  even  the 
simplest  foodA  The  treatment  of  these  cases  is  attended  with  con- 
siderable difficulty ;  recovery,  when  it  does  take  place  (and  it  is  con- 
solatory to  know  that  it  often  does,  even  from  a  condition  apparently 
desperate),  is  brought  about  very  slowly,  and  each  remedy  employed 
seems  speedily  to  become  ineffectual.  Throughout  their  course  two 
objects  are  to  be  borne  in  mind, — one  being  to  check  the  diarrhoea ;  the 
other  to  support  the  child's  strength  during  the  time  required  for  nature 
to  effect  the  cicatrization  of  the  ulcerated  mucous  membrane,  and  to 
restore  it  to  a  state  of  health.  The  utility  of  mercurial  preparations 
has  appeared  to  me  to  be  almost  exclusively  confined  to  the  early  stage 
of  dysentery,  and  to  cease  when  the  disease  has  passed  into  the  chronic 
form.  On  the  other  hand,  astringents  may  now  be  employed  with  the 
most  marked  benefit,  and,  when  one  fails,  another  may  be  substituted  for 
it.  In  cases  where  the  stomach  has  been  very  irritable,  so  that  almost 
everything  has  been  speedily  rejected,  I  have  sometimes  employed  the 
gallic  acid  in  combination  with  laudanum,2  and  have  seen  much  benefit 

(No.  30.) 
2  R  Acidi  Gallici,  gr.  viij. 

Tinct.  Cinnamomi  co.  gj. 

Tinct.  Opii,  TT^viij. 

Syrupi,  gij. 

Aquoe  Cinnamomi,  gv. 

Aquce  pur.  ^j.     M.     gij.  6tis  horis. 


400  TREATMENT   OF   CHRONIC   DIARRH(EA. 

from  its  use.     At  other  times  I  have  given  the  acetate  of  lead  with 

m       opium1 — a  combination  which  retains  its  efficacy,  when  given  in  the 

form  of  mixture,  notwithstanding  the  decomposition  that  takes  place. 

The  sulphate  of  iron  combined  with  opium2  is  another  highly  useful 

(No.  31.)  (No.  32.) 

1  U  Plumbi  Acetat.  gr.  vj.  z  J£  Ferri  Sulphatis,  gr.  iv. 

Aceti  destillati,  n^xx.  Tinct.  Opii,  TT^vj. 

Tinct.  Opii,  TTLviij.  Syrupi  Aurantii,  gij. 

Muc.  Acaciae,  sjij.  Aquae  Carui,  ^x.     M.     gij.  6tis  horis. 
Syrupi  Zingib.  sjj. 

Aquae  purae,  gxiij.     M.  gij.  6tis  horis. 

The  above  are  all  suited  for  children  1  year  old. 

remedy  in  these  cases,  and  appears  to  have  the  advantage  over  the 
sulphate  of  zinc,  wThich  has  likewise  been  used  in  similar  cases,  of  not 
exciting  the  irritability  of  the  stomach. 

Our  remedies  are  not  to  be  confined  to  those  administered  by  the 
mouth ;  for  much  may  be  done  towards  relieving  the  symptoms  and 
curing  the  disease  by  suitable  enemata.  In  some  cases  of  unmanageable 
diarrhoea,  M.  Trousseau  employs  an  enema  of  nitrate  of  silver  in  the 
proportion  of  a  grain  to  an  ounce  of  distilled  water,  which  I  have  some- 
times tried  in  conbination  with  a  few  drops  of  laudanum,  with  very 
good  effect.  I  have  employed  the  gallic  acid  in  enema  in  a  similar 
manner ;  and  throughout  any  case  of  chronic  diarrhoea,  occasion  will 
often  arise  for  altering  our  remedies  in  various  ways,  not  so  much  to 
meet  any  changes  in  the  character  of  the  symptoms,  as  because  all 
medicines,  even  the  most  appropriate,  after  having  been  employed  for 
a  time  seem  to  lose  their  power.  In  the  majority  of  instances  I  have 
begun  with  the  administration  of  clysters  of  laudanum  diffused  in 
mucilage,  or  in  a  small  quantity  of  starch,  while  occasionally,  in  pro- 
tracted cases,  where  the  tenesmus  was  very  distressing,  I  have  used  the 
black  wash  as  a  vehicle  for  the  laudanum ;  and,  on  one  occasion,  in 
which  a  copious  discharge  of  pus  continued  for  several  days  in  a  little 
boy  two  years  old,  this  symptom  was  greatly  relieved  by  the  adminis- 
tration, twice  a  day,  of  an  enema  containing  two  grains  of  sulphate  of 
zinc. 

The  support  of  the  child's  strength  is  a  matter  of  no  less  importance 
in  chronic  dysentery  than  the  suppression  of  the  diarrhoea.  The  great 
weakness  of  the  patient,  and  the  manifest  distaste  for  nourishment  of 
all  kinds,  often  render  it  necessary  to  continue  the  use  of  brandy  for 
several  days,  or  even  for  several  weeks.  For  an  infant  not  weaned, 
there  can  be  no  better  food  than  that  which  is  furnished  by  the  breast 
of  a  healthy  nurse.  In  the  majority  of  cases,  however,  the  child  has 
been  either  in  great  measure  or  altogether  weaned  before  the  affection 
came  on,  and,  consequently,  it  is  a  less  easy  matter  to  supply  it  with 
suitable  food.  Farinaceous  articles,  such  as  arrow-root,  sago,  &c,  are 
less  easily  assimilated  in  early  life  than  in  adult  age,  and  in  cases  of 
this  kind  they  not  infrequently  pass  through  the  alimentary  canal 
unchanged.      Milk,  too,  does   not   always    agree,   and   is   sometimes 


DIET  IN   CHRONIC   DIARRHCEA, — TREATMENT  OF  INTERTRIGO.  401 

rejected  almost  at  once,  unless  it  be  given  in  a  state  of  extreme 
dilution.  Under  these  circumstances  we  must  not  hesitate  to  give 
strong  beef  or  veal  tea  in  small  quantities,  but  at  short  intervals,  to  the 
patient ;  for  though  it  be  true  that  the  bowels  are  often  excited  to 
increased  action,  in  cases  of  chronic  diarrhoea  or  dysentery  by  animal 
broths,  yet  this  is  a  smaller  hazard  than  that  of  the  child  dying  for 
want  of  sufficient  nutriment.  I  may  add,  that,  when  prepared  with 
care,  and  quite  free  from  salt  or  any  seasoning,  and  when  given  cold, 
I  have  seldom  observed  any  serious  increase  of  the  diarrhoea  to  follow 
their  use  under  these  circumstances. 

Two  accidents  are  occasionally  met  with  in  connection  with  pro- 
tracted diarrhoea  in  infants  and  young  children,  concerning  each  of 
which  a  few  words  must  be  said.  It  is  not  unusual  to  observe  a  general 
erythematous  redness  of  the  buttocks  and  nates  in  infants  suffering 
from  severe  diarrhoea,  and  sometimes  the  irritation  of  the  acrid  faeces 
produces  an  attach  of  intertrigo,  and  a  serous  fluid  exudes  abundantly 
from  the  inflamed  skin.  This  condition,  which  is  the  occasion  of  very 
considerable  suffering  to  the  child,  almost  always  depends  upon  a 
neglect  of  that  most  scrupulous  cleanliness  which  is  of  such  essential 
importance  in  early  life.  In  order  to  prevent  its  occurrence,  the  nates 
and  buttocks  must  be  sponged  with  warm  water  immediately  after  each 
evacuation ;  the  surface  may  afterwards  be  smeared  with  a  little  zinc 
ointment,  while  any  part  at  which  the  skin  seems  disposed  to  crack 
should  be  dusted  over  with  the  oxide  of  zinc  in  powder.  These  simple 
precautions  will  usually  suffice  to  prevent  a  condition  which,  in  some  of 
the  hospitals  \pf  Paris,  where  such  sedulous  care  is  almost  impossible, 
degenerates  into  a  state  of  unhealthy  ulceration  that  exhausts  the 
infant's  powers,  and  sometimes  contributes  to  its  destruction  quite  as 
much  as  the  diarrhoea  in  the  course  of  which  it  came  on. 

Prolapsus  of  the  anus  is  another  troublesome  accident  which  some- 
times takes  place  in  the  course  of  protracted  diarrhoea.  It  abates, 
however,  almost  always,  as  the  diarrhoea  diminishes,  and  generally  ceases 
altogether  as  the  child  regains  its  strength.  When  there  is  a  disposi- 
tion to  it  during  the  acute  stage  of  the  affection,  this  may  often  be 
controlled  if  the  nurse  be  instructed  to  support  the  margin  of  the  anus 
during  each  evacuation,  and  thus  to  prevent  the  descent  of  the  bowel, 
while  the  opiate  enema  which  relieves  the  tenesmus  is  of  most  essential 
service,  by  thus  removing  the  cause  of  the  prolapse.  The  child's 
attendant  should  also  be  taught  how  to  return  the  bowel  if  it  should 
come  down ;  and  this  is  best  effected  by  means  of  gentle  pressure  with 
a  napkin  wrung  out  of  cold  water.  If,  as  the  diarrhoea  abates,  the 
prolapse  should  still  continue,  and  especially  if  the  gut  should  come 
down  independent  of  efforts  at  defaecation,  it  may  be  necessary  to  make 
the  child  wear  a  compress  and  bandage  to  prevent  its  descent.  In  such 
cases,  too,  an  enema  consisting  of  a  small  quantity  of  some  astringent, 
such  as  the  decoction  of  tormentilla,  should  be  administered  cold  once 
or  twice  a  day;  and  no  instance  has  come  under  my  notice  in  which 
these  measures,  persevered  in  for  a  few  weeks,  have  not  sufficed  to 
remove  this  troublesome  ailment. 

26 


402  PERITONITIS. 


LECTURE    XXXIV. 

Peritonitis — sometimes  occurs  during  foetal  existence,  or  in  very  early  infancy — is 
then  possibly  dependent  on  syphilitic  taint — when  epidemic  in  large  institutions  is 
often  connected  with  infantile  erysipelas. 

Peritonitis  in  after-childhood — a  rare  occurrence — generally  secondary  to  some  febrile 
attack — case  illustrative  of  its  symptoms,  which  are  much  the  same  as  in  the  adult — 
occasional  escape  of  the  fluids  effused,  through  the  abdominal  walls,  and  recovery  of 
the  patient. — Inflammation  sometimes  circumscribed,  especially  in  connection  with 
disease  about  the  appendix  caeci — illustrative  case. — Treatment  of  peritonitis. 

Chronic  peritonitis — almost  always  a  tubercular  disease. — Morbid  appearances — symp- 
toms— their  vagueness — pauses  in  the  advance  of  the  disease — various  and  often 
obscure  forms  which  it  assumes — close  analogy  between  its  symptoms  and  those 
referred  to  tubercular  disease  of  the  mesenteric  glands. 

Tabes  Mesenterica — rarity  of  extensive  disease  of  the  glands — slightness  of  its  symptoms 
when  uncomplicated. — Treatment  of  it,  and  of  tubercular  peritonitis. 

From  the  study  of  the  affections  of  the  mucous  lining  of  the  intestinal 
canal,  we  pass  by  a  natural  transition  to  that  of  the  diseases  of  its 
serous  investment.  Peritonitis,  however,  which  is  not  very  common  as 
an  idiopathic  affection  at  any  period  of  life,  is  still  more  rare  during 
the  greater  number  of  the  years  of  childhood ;  while  its  symptoms  do 
not  deviate  in  any  important  respect  from  those  which  characterise  it  in 
the  adult.  It  would  be  idle  to  spend  our  time  in  speculating  on  the 
reasons  for  the  rarity  of  inflammation  of  the  peritoneum  in  early  life. 
The  tendency  of  inflammatory  disease  in  childhood  appears,  indeed,  to 
be  to  attack  the  mucous  rather  than  the  serous  membranes;  a  fact  of 
which  we  have  another  illustration  in  the  comparative  rarity  of  acute 
pleurisy  in  the  child.  Some  connection  may  perhaps  be  thought  to 
subsist  between  the  great  irritability  of  the  intestinal  mucous  membrane, 
and  its  proneness  to  disease  during  the  greater  part  of  childhood  on  the 
one  hand;  and  the  immunity  from  disease  which  the  peritoneum  exhibits 
during  the  same  period.  At  any  rate,  it  is  certain  that  in  the  new-born 
infant,  in  whom  the  former  peculiarity  has  not  yet  become  developed, 
inflammation  of  the  peritoneum  is  of  more  common  occurrence  than  in 
subsequent  childhood. 

Inflammation  of  the  peritoneum,  giving  rise  to  adhesions  between  the 
intestines,  and  to  the  effusion  of  lymph  and  serum  into  the  cavity  of 
the  abdomen,  occurs  sometimes  even  during  intra-uterine  life,  and  occa- 
sions the  death  of  the  foetus.  It  is  not  possible  to  say  with  certainty 
to  what  cause  the  disease  should  be  attributed,  at  a  time  when  the  being 
is  sheltered  from  all  those  influences  from  without  which  may  excite 
inflammation  after  birth ;  but  it  is  worthy  of  notice  that  in  many 
instances  of  peritonitis  in  the  foetus,  traces  of  syphilitic  disease  are 
observed  upon  it;  or  there  is  clear  evidence  of  the  existence  of  venereal 
taint  in  the  mother.  In  such  cases,  the  inflammation  of  the  serous  lining 
of  the  abdomen  is  probably  due  to  the  altered  state  of  the  circulating 
fluid — a  cause  to  which,  in  after  life,  inflammation  of  the  serous  mem- 
branes is  frequently  owing.     In  the  only  instances  of  non-congenital 


PERITONITIS   IN   EARLY   INFANCY.  403 

peritoneal  inflammation  that  has  come  under  my  notice  in  early  infancy, 
there  was  no  other  cause  than  this  to  which  it  could  be  attributed. 

In  this  case,  a  little  boy,  five  weeks  old  (whose  mother  had  twice 
before  been  confined  prematurely  with  still-born  children),  began  to  have 
snuffles  at  the  age  of  three  weeks.  In  the  course  of  the  next  week  a  few 
copper-coloured  spots  appeared  about  his  face;  his  scrotum  next  grew 
sore,  then  his  voice  became  hoarse  and  his  lips  cracked ;  and  at  the  end 
of  the  fourth  week  he  grew  sick,  and  his  abdomen  enlarged  and  became 
tender.  When  brought  to  me  the  child  was  extremely  small;  he  was 
greatly  emaciated;  the  skin  of  his  face  wrinkled;  his  appearance  dis- 
tressed ;  his  chin  covered  with  copper-coloured  blotches  ;  the  angles  of 
his  mouth  were  ulcerated ;  his  lips  cracked ;  and  small  sores  beset  his 
scrotum.  His  abdomen  likewise  was  very  large :  it  was  remarkably 
prominent  about  the  umbilicus,  and  its  superficial  veins  were  much 
enlarged.  It  was  extremely  tense ;  somewhat  tympanitic ;  and  though 
dull  in  places,  it  yet  did  not  yield  the  impression  of  distinct  fluctuation 
anywhere.  The  abdomen  was  exceedingly  tender  to  the  touch,  but  the 
child  seemed  in  pain  also  at  other  times ;  he  had  been  very  sick  for 
nearly  a  week,  and  vomited  almost  immediately  after  sucking,  besides 
which  he  threw  up  a  yellow  fluid  at  other  times.  His  bowels  were 
purged  several  times  a  day.  His  mother,  who  did  not  suffer  at  that  time 
from  any  syphilitic  symptom,  was  put  upon  a  mild  mercurial  course, 
with  iodide  of  potassium  and  sarsaparilla ;  and  the  mercury  with  chalk 
was  likewise  administered  to  the  child.  By  degrees,  as  the  syphilitic 
spots  faded,  the  abdomen  grew  less  tender  and  less  swollen, — it  became 
soft ;  and  in  the  course  of  time  the  infant  regained  perfect  health. 

The  symptohjs  in  this  case  ran  a  chronic  course ;  but  peritonitis  of  an 
acute  character,  and  tending  to  a  rapidly  fatal  termination,  is  sometimes 
observed  to  occur  among  very  young  infants  when  collected  together  in 
large  numbers,  and  under  conditions  unfavourable  to  health.  A  French 
physician,  M.  Thore,1  during  a  year's  observation  at  the  Hospice  des 
Enfans  Trouve*s  at  Paris,  found  that  acute  peritonitis  existed  in  about 
six  per  cent,  of  the  infants  who  died  at  that  institution.  The  disease, 
such  as  he  observed  it,  seems  to  be  exclusively,  an  affection  of  early 
infancy,  since,  though  the  hospice  contains  children  of  all  ages,  yet  no 
child  above  the  age  of  ten  weeks  was  attacked  by  it,  while  thirty-five 
out  of  fifty-nine  were  less  than  a  fortnight  old.  The  previous  health  of 
the  children  had  in  some  instances  been  good,  but  in  many  cases  the 
peritonitis  appeared  as  a  consequence  or  complication  of  some  other 
affection.  A  sudden  tympanitic  swelling  of  the  abdomen  was  often  the 
first  symptom  of  the  disease,  and  was  soon  associated  with  vomiting  of 
a  greenish  matter ;  which  phenomenon,  however,  was  seldom  of  long 
continuance.  The  bowels  were  generally  constipated  throughout,  the 
respiration  and  pulse  soon  became  accelerated,  and  the  heat  of  skin 
increased,  while  the  child  evidently  suffered  pain  in  the  abdomen. 
With  the  advance  of  the  disease  the  countenance  altered,  the  skin  grew 
cold,  and  the  pulse  feeble ;  and  in  the  majority  of  cases  the  child  died 

1  De  la  Pe'ritonite  chez  les  Nouveau-ne's,  in  the  Archives  Ge*n.  de  Med.  for  August  an 
September,  184(5. 


404  PERITONITIS   SOMETIMES   EPIDEMIC   IN   HOSPITALS. 

within  twenty-four  hours,  while  life  was  not  in  any  instance  prolonged 
beyond  the  third  day. 

The  appearances  found  after  death  were  much  the  same  as  those 
which  characterise  peritonitis  in  the  foetus.  In  none  of  the  sixty-three 
cases  which  were  examined  was  there  any  puriform  matter  in  the  abdo- 
minal cavity,  but  only  a  dirty  serous  fluid,  in  which  flocculi  of  lymph 
were  often  floating ;  while  the  intestines  were  more  or  less  coated  with 
false  membrane,  which  was  especially  abundant  about  the  spleen  and 
liver.  Pleurisy  was  found  associated  with  the  peritonitis  in  a  third  of 
the  cases ;  and  the  frequency  of  this  complication  is  another  point  of 
resemblance  between  the  disease  as  it  occurs  during  foetal  life  and  in 
early  infancy.  Its  causes,  too,  appear  to  be  such  as  act  through  the 
medium  of  the  circulating  fluid ;  for  in  seventeen  out  of  sixty-three  cases 
the  peritonitis  followed  on  erysipelas,  and  in  four  on  phlebitis  of  the 
umbilical  vein — affections  which,  it  is  known,  are  immediately  dependent 
on  epidemic  causes,  and  are  excited  by  the  same  atmospheric  conditions 
as  induce  puerperal  fever  in  lying-in  women.  The  influence  of  such 
agencies  is  still  farther  shown  by  the  fact  that  forty-two  per  cent,  of 
the  cases  of  peritonitis  recorded  by  M.  Thore  occurred  during  the  months 
of  April  and  May,  while  the  others  were  somewhat  unequally  distributed 
over  the  remainder  of  the  year. 

When  the  child  grows  older  it  is  no  longer  so  susceptible  of  noxious 
influences  as  before ;  and  when  they  come  into  play,  the  mucous  mem- 
brane of  the  bowels  suffers,  rather  than  their  serous  investment.  Hence, 
acute  idiopathic  peritonitis  becomes  a  very  rare  disease  in  childhood : 
and  peritoneal  inflammation  usually  occurs  as  a  sequela  of  some  affection 
which  has  been  attended  with  considerable  alteration  in  the  circulating 
fluid.  It  sometimes  succeeds  to  an  attack  of  scarlatina ;  and  the  possi- 
bility of  its  occurrence  should  lead  us  to  look  with  great  suspicion  upon 
any  complaint  of  pain  in  the  abdomen  made  by  children  during  their 
convalescence  from  that  disease ;  while,  though  the  danger  of  its  super- 
vention after  other  febrile  affections  is  less  considerable,  the  risk  is  by 
no  means  to  be  forgotten. 

The  symptoms  and  course  of  the  disease  appear  to  be  much  the  same 
whether  it  occurs  as  a  primary  or  as  a  secondary  affection ;  but  there 
is  a  great  difference  between  the  severity  of  the  symptoms  and  the 
amount  of  danger  to  which  the  patient  is  exposed,  in  different  cases. 

I  do  not  recollect  ever  to  have  witnessed  more  intense  suffering  than 
was  endured  by  a  little  boy,  nine  years  old,  who,  after  recovering  from 
fever,  yet  seemed  to  regain  his  health  by  but  slow  degrees,  and  had 
almost  habitual  constipation.  He  came  under  my  notice  on  May  25, 
and  was  much  benefited  by  alterative  and  slightly  aperient  medicines  ; 
when  he  was  suddenly,  and  without  any  known  cause,  seized  on  the  3d 
of  June  with  profuse  diarrhoea,  and  severe  pain  in  the  abdomen.  On 
the  following  day,  when  I  saw  him,  his  face  was  haggard  and  anxious, 
and  his  abdomen  excessively  tender ;  while  the  diarrhoea  continued  even 
more  profusely  than  before.  Some  leeches  were  applied  to  the  abdo- 
men, and  calomel  and  Dover's  powder  were  given  every  four  hours  ;  but 
the  leeches  drew  but  little  blood,  and  though  the  purging  ceased,  the 
pain  iii  the  abdomen  increased  in  severity.    On  the  5th  of  June  I  found 


SYMPTOMS   OF  ACUTE   PERITONITIS  IN   CHILDREN.  405 

the  boy  lying  on  his  back,  with  his  legs  stretched  straight  out ;  while 
the  slightest  movement,  or  any  attempt  to  sit  up,  produced  excruciating 
pain.  The  abdomen  was  tympanitic,  very  tender  to  the  touch,  and 
especially  so  just  below  the  umbilicus.  The  pulse  was  frequent  and 
sharp ;  the  tongue  moist,  and  uniformly  coated  with  yellow  fur.  Leeches 
were  again  applied,  in  greater  numbers  than  before :  and  the  mercurial 
was  given  every  three  instead  of  every  four  hours.  Towards  evening 
he  was  rather  better,  but  the  pain,  which  was  referred  especially  to  the 
neighbourhood  of  the  umbilicus,  came  on  severely  during  the  night,  and 
was  aggravated  in  paroxysms.  He  had  passed  no  urine  for  many 
hours ;  but  only  half  a  pint  was  drawn  off  by  the  catheter,  and  this 
was  dark  coloured,  and  had  a  very  strong  smell.  The  bowels  had  acted 
only  once,  and  then  scantily.  The  same  remedies  were  continued,  but 
the  child's  condition  continued  to  grow  worse ;  and  during  the  night  he 
was  in  such  pain  that  he  frequently  shrieked  aloud  so  as  to  alarm  the 
neighbours.  On  the  morning  of  the  7th  he  had  turned  round  upon  his 
right  side,  and  lay  with  his  knees  drawn  up  towards  his  abdomen,  his 
head  supported  in  his  mother's  lap ;  his  face  expressed  the  most  intense 
suffering,  and  he  shrieked  frequently  with  pain.  The  abdomen  was 
much  distended,  and  so  tender  that  it  could  not  endure  the  slightest 
touch.  The  pulse  had  become  frequent  and  thready.  He  had  made 
water  twice  of  his  own  accord.  The  abdomen  was  now  covered  with  a 
large  blister:  beef-tea  and  brandy  were  given  to  support  the  vital 
powers ;  and  while  the  mercurial  was  continued,  an  endeavour  was 
made,  by  a  full  dose  of  opium,  to  procure  a  temporary  abatement  of 
the  child's  sufferings.  When  seen  at  6  P.  M.  he  had  vomited  frequently 
a  dark-green  fluid,  and  had  passed  three  natural  liquid  evacuations. 
He  was  lying  in  the  same  attitude  as  before,  dozing  with  half-closed 
eyes,  his  forehead  wrinkled,  the  corners  of  his  mouth  drawn  down, 
terror  and  pain  stamped  on  his  countenance, — seeming  as  if  dying,  till 
roused  by  a  return  of  pain,  when  he  called  with  loud  and  piteous  cries 
on  his  mother  for  help.  His  pulse  was  now  smaller,  and  more  thready. 
During  the  night  his  sufferings  were  unceasing ;  towards  morning  he 
became  quieter,  and  died  quietly  at  9  A.  M.,  on  June  the  8th. 

On  opening  the  abdomen,  thin  pus,  unmixed  with  lymph,  poured 
forth  in  great  abundance.  It  quite  concealed  the  intestines  from  view, 
and  must  have  amounted  to  at  least  a  quart.  The  peritoneal  lining  of 
the  abdominal  walls  was  highly  vascular,  especially  in  the  hypogastric 
region ;  that  covering  the  intestines  had  lost  its  natural  transparency, 
was  softer,  and  seemed  thicker,  but  was  not  much  injected.  There  was 
no  lymph  effused  on  any  part  of  the  parietal  peritoneum,  nor  were  there 
any  adhesions  between  the  intestines ;  but  the  spleen  and  liver,  the  latter 
especially  on  its  convex  surface,  were  coated  with  lymph.  The  whole 
tract  of  the  intestines  was  examined  with  great  care,  and  was  found  to 
be  quite  healthy ;  the  mucous  membrane  being  rather  pale.  There  was 
.  some  crude  tuberculous  matter  in  the  mesenteric  glands.  The  right 
side  of  the  chest  contained  a  pint  of  pus,  similar  to  that  in  the  abdo- 
men ;  the  right  pleura  was  intensely  vascular,  and  this  condition  was 
especially  remarkable  in  that  part  of  it  which  lined  the  diaphragm :  a 
patch  of  lymph,  of  small  extent,  formed  a  connection  between  the  two 


406  CASE   OF  ACUTE   PERITONITIS. 

surfaces  of  the  lung,  while  the  right  lung  generally  had  a  rather  thick 
coating  of  false  membrane.  Some  tubercles  in  the  bronchial  glands, 
and  a  compressed  state  of  the  substance  of  the  right  lung,  formed  the 
rest  of  the  morbid  appearances. 

There  can  be  no  doubt  but  that,  in  the  early  stages  of  this  case,  a 
more  active  plan  of  treatment  ought  to  have  been  adopted.  It  is  related, 
however,  not  as  an  illustration  of  the  therapeutical  principles  by  which 
you  should  be  guided,  but  as  affording  a  remarkably  good  specimen  of 
the  symptoms  of  acute  peritonitis.  The  inflammation  of  the  pleura  was 
doubtless  secondary  to  that  of  the  peritoneum,  and  the  effusion  into  the 
cavity  of  the  chest  probably  coincided  with  the  time  when  the  child 
assumed  the  position  on  his  right  side.  We  learn  from  this  case,  that 
pain,  coming  on  suddenly,  referred  particularly  to  one  part  of  the 
abdomen,  but  extending  over  the  wThole,  greatly  aggravated  on  pres- 
sure, or  on  the  slightest  movement,  so  as  to  compel  the  patient  to 
remain  in  the  recumbent  posture,  with  the  legs  extended  and  motionless, 
characterize  the  disease.  The  abdomen  before  long  becomes  tympanitic, 
and  this  tympanitis,  if  considerable,  greatly  aggravates  the  patient's 
sufferings.  The  state  of  the  bowels  varies :  frequently  they  are  relaxed 
at  the  outset  of  the  illness ;  sometimes  they  continue  so  throughout, 
while  they  are  but  rarely  constipated.  Vomiting  is  not  ,a  constant 
symptom ;  and  when  it  does  occur,  the  irritability  of  the  stomach 
varies,  both  in  its  degree  as  well  as  in  the  time  at  which  it  appears. 
The  symptoms  sometimes  continue  to  increase  in  severity  until  death 
takes  place ;  at  other  times  they  undergo  a  sudden  diminution,  or  even 
cease  altogether;  though  this  seeming  amendment  is  attended,  or 
rapidly  followed,  by  sinking  of  the  vital  powers,  and  soon  afterwards 
by  the  patient's  death. 

Acute  general  peritonitis  is  fortunately  very  rare  in  childhood — only 
three  other  instances  of  it  have  come  under  my  notice ;  and  still  rarer 
is  its  termination  by  the  effusion  of  pus  into  the  cavity  of  the  abdomen. 
Even  under  these  apparently  hopeless  circumstances,  however,  nature 
does  sometimes  make  an  effort  at  cure.  The  active  symptoms  diminish 
in  intensity ;  the  abdominal  parietes  grow  thin  at  some  spot,  where  a 
passage  at  length  is  formed  through  which  the  pus  is  discharged,  and 
recovery  sometimes  slowly  follows ;  the  result  of  a  process  precisely 
analogous  to  that  which  nature  has  recourse  to  in  pleurisy,  when  she 
brings  about  the  evacuation  of  the  fluid  through  an  opening  sponta- 
neously formed  in  the  parietes  of  the  thorax.  An  instance  of  this 
mode  of  cure  of  peritonitis,  in  a  child  seven  years  old,  was  related 
by  Dr.  Aldis,  at  a  meeting  of  the  Medico-Chirurgical  Society,  in 
November,  1846. 1  A  few  similar  cases  may  be  found  in  medical 
journals  ;2  and  one  has  come  under  my  own  observation,  in  the  person 
of  a  little  girl,  whose  history  I  formerly  related,3  as  affording  an  illus- 
tration of  that  rare  affection,  inflammation  of  the  sinuses  of  the  dura 
mater. 

1  Reported  in  the  London  Medical  Gazette,  November,  1846. 

2  For  instance,  Bernhardi,  in  Preuss.  Med.  Zeitung,  1842,  No.  10;  and  Beyer,  Casper's 
Wochenschr.  1842,  No.  5. 

3  See  Lecture  VII.  p.  88. 


SYMPTOMS  OF  ACUTE  GENERAL  PERITONITIS.  407 

The  peritoneal  inflammation  which  comes  on  during  scarlatinal  dropsy- 
is  not  in  general  of  a  very  active  character,  and  seldom  produces  any 
morbid  appearance  of  greater  gravity  than  numerous  slight  adhesions 
between  the  intestines.  It  generally  succeeds  to  ascites ;  and  the 
abdominal  affection  seldom  exists  alone,  but  is  usually  associated  with 
pleurisy,  and  abundant  serous  effusion  into  the  chest';  and  the  symptoms 
of  disease  of  the  respiratory  organs  very  often  mask  those  of  the  abdo- 
minal inflammation,  which  latter,  indeed,  seem  in  many  instances  to 
have  but  a  very  subsidiary  share  in  bringing  about  the  patient's  death. 

Besides  those  cases  in  which  the  peritonitis  is  general,  there  are 
others  in  which  the  inflammation  is  circumscribed  to  a  'part,  and  some- 
times but  a  small  part,  of  the  peritoneum.  Now  and  then,  peritonitis 
affecting  only  a  very  small  extent  of  surface  proves  rapidly  fatal, 
(though  no  such  instance  has  come  under  my  own  notice) ;  but  usually 
there  is  a  correspondence  between  the  severity  of  the  symptoms, 
and  the  extent  of  the  disease.  I  imagine  the  inflammation  to  have 
been  circumscribed  in  some  cases,  in  which  the  principal  pain  was 
referred  to  one  part  of  the  abdomen,  while  the  tenderness  was  almost 
limited  to  that  situation,  in  which,  moreover,  the  abdomen  did  not 
become  generally  tense  or  tympanitic,  and  all  the  symptoms  yielded 
with  tolerable  readiness  to  the  employment  of  remedies,  though  the 
disposition  to  pain  and  tenderness  in  one  spot  was,  some  time  before  it 
wholly  disappeared. 

Lastly,  some  notice  must  be  taken  of  a  highly  dangerous  form  of 
peritonitis,  circumscribed  in  some  cases,  but  general  in  others,  which 
succeeds  to  inflammation  of  the  csecum,  or  of  its  vermiform  appendix. 
This  affection\  however,  is  not  so  common  in  early  life  as  in  adult  age, 
while  the  same  symptoms  characterise  it  in  either  case ;  so  that  no 
lengthened  description  of  it  will  be  necessary.  It  has  only  once  come 
under  my  observation,  and,  in  that  instance,  although  the  inflammation 
had  produced  gangrene  of  the  mucous  membrane  of  the  appendix,  and 
a  sloughing  opening  of  communication  between  it  and  an  abscess  in  the 
cellular  tissue  behind  the  caecum,  yet  no  intestinal  concretion  or  other 
foreign  body  was  discovered,  to  the  lodgment  of  which,  in  the  appendix, 
the  disease  could  be  attributed.  All  the  viscera  in  the  right  half  of 
the  abdomen  were  thickly  coated  with  lymph,  but  the  inflammation 
had  not  at  all  involved  the  parietal  peritoneum,  nor  extended  to  the 
intestines  on  the  left  of  the  mesial  line.  Acute  pleurisy,  however, 
existed  on  the  right  side,  and  had  given  rise  to  the  effusion  of  nearly 
three  pints  of  milky  serum.  The  patient  was  a  little  boy,  only  seven 
years  old,  whose  health  had  been  habitually  good,  till  he  began  to 
complain,  on  the  5th  of  July,  of  pain  in  the  abdomen,  and  was  attacked 
at  the  same  time  with  violent  purging  and  vomiting.  The  purging 
ceased  in  the  course  of  a  few  hours,  but  the  vomiting  continued  at  the 
time  of  my  seeing  him  on  July  8,  when  he  likewise  complained  of  great 
pain,  and  of  exquisite  tenderness  in  the  right  hypochondriac  region. 
Leeches  were  twice  applied  in  that  situation,  with  manifest  relief,  and 
calomel  and  opium  were  given  every  three  hours.  In  the  night  of  the 
10th,  an  aggravation  of  the  symptoms  took  place,  and  auscultation 
detected  a  friction  sound  in  the  right  side  of  the  chest.     Cupping 


408        PERITONITIS   CONSEQUENT   ON   INFLAMMATION   OF   THE   CAECUM. 

beneath  the  right  scapula  was  followed  by  a  very  marked  improvement: 
he  rested  well  on  the  night  of  the  11th ;  and  on  the  12th,  he  not  only 
breathed  without  difficulty,  but  was  free  from  pain  in  the  hypochon- 
drium,  except  on  pressure,  and  the  sickness  had  completely  ceased. 
An  aggravation  of  his  symptoms,  however,  occurred  during  the  night : 
on  the  13th,  he  changed  his  attitude,  and  lay  on  his  right  side  instead 
of  on  his  back,  and  retained  this  posture  till  his  death.  A  marked 
fulness  was  now  apparent  on  the  right  side,  extending  from  the  crest  of 
the  ilium  to  the  ribs.  On  the  ensuing  day  this  part  was  not  merely 
full  and  tender,  but  exceedingly  firm  to  the  touch, — a  condition  which 
existed  throughout  the  whole  lumbar  region,  and  extended  forward  to 
about  two  inches  to  the  right  of  the  linea  alba.  The  bowels  were  at  no 
time  much  constipated,  and  after  the  administration  of  an  aperient  on 
the  12th,  they  acted  several  times  each  day,  the  motions  being  relaxed, 
but  otherwise  natural.  Sickness  returned  on  the  13th,  and  during  the 
last  two  days  of  the  child's  life  it  was  almost  constant ;  while  the  great 
thirst  that  existed  during  the  whole  course  of  the  illness  rendered  this 
symptom  the  more  distressing.  On  the  12th,  there  were  physical  signs 
of  some  effusion  into  the  chest,  which  had  increased  so  much  before 
death  that  the  right  half  of  the  chest  was  manifestly  enlarged,  and  the 
intercostal  spaces  on  that  side  were  very  prominent.  Auscultation  of 
the  back  of  the  chest  was  however  impossible  for  some  days,  owing 
to  the  acute  pain  produced  by  any  movement.  The  breath  grew  very 
short ;  the  flesh  wasted  rapidly ;  the  face  was  habitually  expressive  of 
distress,  and  at  night  delirium  came  on.  On  the  16th,  after  a  most 
wretched  night,  his  pulse  became  very  feeble,  and  his  extremities  cold, 
while  the  vomiting  was  incessant.  Convulsions  came  on,  and  lasted 
for  six  hours,  when  they  ceased,  and  two  hours  afterwards  the  child 
died  tranquilly,  on  the  11th  day  from  the  first  sign  of  indisposition. 
The  mercurial  treatment  had  been  continued  all  along,  the  opium  being 
increased  as  the  intensity  of  the  child's  sufferings  seemed  to  require, 
and  four  days  before  death  the  inunction  of  a  drachm  of  strong 
mercurial  ointment  every  four  hours  was  begun ;  but  no  effect  seemed 
to  be  produced  by  the  remedies. 

The  indications  for  treatment,  in  cases  of  acute  peritonitis,  are  so 
clear  that  it  would  be  superfluous  to  occupy  much  time  in  laying  down 
rules  for  your  guidance.  You  have  to  deal  with  the  active  inflamma- 
tion of  parts  in  which  acute  disease  cannot  goon  long  without  destroying 
life.  Depletion,  both  general  and  local,  and  the  employment  of  mer- 
cury, combined  with  opium  or  Dover's  powder,  in  order  to  mitigate 
the  suffering  which  attends  on  the  disease,  are  the  remedies  to  which 
you  must  have  recourse,  and  which  you  must  employ  with  an  unsparing 
hand.  When  the  abdominal  tenderness  has  been  mitigated  by  bleed- 
ing, a  warm  poultice,  frequently  renewed,  will  often  afford  considerable 
comfort ;  and  in  some  cases  of  local  peritonitis  I  have  seen  the  warm 
hip-bath  give  much  relief.  The  error  into  which  you  are  likely  to  fall 
in  the  management  of  these  cases  is  not  that  of  pursuing  a  wrong 
course,  but  of  following  the  right  one  with  too  little  vigour. 

In  the  peritonitis  that  follows  scarlatina,  the  symptoms  are  often  less 
urgent  than  under  other  circumstances ;  but  you  will  bear  in  mind, 


TUBERCULAR  PERITONITIS.  409 

that  when  the  function  of  the  kidneys  is  disturbed,  and  urea  is  circu- 
lating in  the  blood,  the  serous  membranes  are  very  apt  to  become 
inflamed,  and  you  will,  therefore,  keep  on  the  look-out  for  any  indica- 
tion of  their  suffering.  I  shall  hereafter  have  to  point  out  to  you,  that 
in  this,  as  well  as  in  so  many  other  cases,  prevention  is  not  only  better, 
but  easier  than  cure  ;  and  that  if  on  the  first  appearance  of  the  dropsy 
consecutive  on  scarlet  fever,  you  have  recourse  to  active  antiphlo- 
gistic measures,  you  will,  in  the  large  majority  of  cases,  escape  the  risk 
of  these  secondary  inflammations. 

Acute  peritonitis,  like  the  acute  inflammation  of  any  other  tissue, 
may  subside,  but  not  altogether  cease ;  it  may  pass  into  a  chronic 
state,  and  the  patient  may  suffer  from  the  consequences  of  the  disease 
long  after  the  disease  in  its  original  form  has  disappeared.  But  it  is 
not  to  an  affection  of  this  kind  that  I  wish  to  call  your  attention  in 
speaking  of  chronic  peritonitis;  but  to  a  disease,  the  progress  of  which 
is  slow  from  its  commencement,  which  is  weeks  or  months  in  running 
its  course,  but  which  yet  demands  our  closest  attention,  since  in  a  very 
large  number  of  cases  that  course  is  to  a  fatal  issue. 

It  is  not,  however,  its  tardy  progress  which  alone  distinguishes  the 
chronic  from  the  acute  inflammation  of  the  peritoneum,  but  the  former 
is  almost  invariably  associated  with  the  tuberculous  cachexia,  and, 
indeed,  generally  succeeds  to  the  deposit  of  tubercle  upon  the  serous 
membrane  of  the  abdomen.  The  occasional  recovery  of  a  child  in 
whom  the  symptoms  of  chronic  peritonitis  have  existed,  by  no  means 
disproves  that  connection  between  it  and  phthisical  disease,  of  which 
dissection  in  fatal  cases  affords  such  convincing  proof. 

The  bodies®/  children  who  have  died  of  this  affection  are  usually 
found  to  be  exceedingly  emaciated  ;  and  their  face  retains  after  death 
the  suffering  expression  which  it  had  worn  during  their  protracted  ill- 
ness. The  lungs  and  bronchial  glands  contain  tubercle  in  greater  or 
less  abundance,  and  the  pulmonary  disease  is  sometimes  so  far  advanced 
as  to  have  obviously  had  no  small  share  in  bringing  about  the  fatal 
event.  On  dividing  the  abdominal  parietes,  long,  slender,  cellular, 
adhesions,  are  often  found  connecting  the  peritoneum  to  the  subjacent 
viscera.  The  intestines,  too,  are  connected  by  adhesions,  some  of 
which  are  very  easily  broken  down,  while  others  are  so  firm  that  the 
coats  of  the  bowels  give  way  in  the  attempt  to  separate  them.  This 
difference  does  not  depend  on  the  age  of  the  adhesions  (although  in 
this  respect  they  vary  greatly,  some  being  apparently  of  very  recent 
date,  others  of  long  standing),  so  much  as  on  their  nature.  Those 
connections  which  are  formed  by  the  mere  effusion  of  lymph,  even 
when  from  age  they  have  acquired  considerable  firmness,  can  gene- 
rally be  broken  down  without  much  difficulty ;  and  at  any  rate  the 
attempt  will  not  produce  rupture  of  the  intestines.  When,  however, 
different  portions  of  the  bowel  are  matted  together  so  inseparably  that 
it  is  easier  to  lacerate  than  to  detach  them  from  each  other,  it  will  be 
found  that  something  more  than  the  mere  effusion  of  lymph  has  pro- 
duced this  union.  It  will  be  seen  to  have  been  effected  by  means  of  a 
yellow,  granular  matter,  like  that  which  connects  the  opposite  surfaces 
of  the  arachnoid  in  a  case  of  tubercular  hydrocephalus,  and  made  up 


410  MORBID  APPEARANCES. 

like  it  in  part  of  lymph,  in  part  of  tubercular  deposits.  Adhesions 
are  thus  formed  between  the  opposite  surfaces  of  peritoneum,  at  first 
of  small  extent,  but  fresh  deposits  of  tubercle  soon  take  place  in  the 
vicinity,  and  the  attendant  inflammatory  process  unites  together  a  still 
greater  extent  of  intestine.  Nor  is  this  all ;  but  in  time,  the  tubercle 
thus  deposited  undergoes  a  process  of  softening,  in  the  course  of  which 
the  muscular  tissue  of  the  intestines  becomes  destroyed,  and  their 
mucous  membrane  may  thus  eventually  be  perforated,  so  that  distant 
parts  of  the  intestinal  canal,  which  at  first  were  merely  adherent 
together,  are  sometimes  brought  by  this  means  into  direct  communica- 
tion with  each  other.  The  abdomen  generally  contains  a  small  quantity 
of  transparent  serum ;  but  if,  as  sometimes  happens,  life  should  have 
been  cut  short  by  the  supervention  of  acute  peritonitis  upon  the  old 
disease,  the  effusion  may  be  of  a  puriform  or  sero-purulent  character ; 
though  this  is  seldom  abundant. 

In  addition  to  the  evidences  of  inflammatory  action  presented  by 
the  peritoneum,  that  membrane  and  the  various  abdominal  viscera  are 
the  seat  of  a  more  or  less  generally  diffused  tubercular  deposit.  The 
surface  of  the  peritoneum  lining  the  abdominal  walls  is  sometimes 
abundantly  beset  with  small,  grey,  semi-transparent  granulations  ;  but 
in  the  majority  of  cases  the  tuberculization  is  less  general,  and  the 
parietal  peritoneum  is  less  affected  than  other  parts  of  the  membrane. 
That  part  of  the  peritoneum  which  lines  the  diaphragm,  or  the  abdom- 
inal walls  in  the  immediate  vicinity  of  the  spleen,  is  one  of  the  favourite 
seats  of  tubercular  deposit,  which  in  these  situations  generally  put  on 
the  form  of  small,  yellow,  miliary  tubercles,  not  that  of  grey  granula- 
tions. In  some  instances  the  omentum  is  the  seat  of  the  chief  tuber- 
cular deposit ;  and  though  it  usually  assumes  the  miliary  form,  yet 
now  and  then  masses  of  crude  tubercle  of  considerable  size  are  met 
with  in  this  situation.  The  peritoneum  covering  the  liver  and  spleen 
seldom  fails  to  shew  an  abundant  deposit  of  tubercle ;  and  tubercles 
usually  abound  in  the  substance  of  the  latter  organ.  The  mesenteric 
glands  likewise  are  tuberculous,  though  the  degree  of  their  degenera- 
tion, and  the  size  which  they  have  in  consequence  attained,  vary  much 
in  different  cases.  The  same  remark  holds  good  with  reference  to  the 
amount  of  tubercular  disease  in  the  interior  of  the  intestines,  which, 
though  in  many  cases  very  considerable,  yet  bears  no  invariable  rela- 
tion either  to  the  degree  of  the  affection  of  the  peritoneum,  or  to  that 
of  the  mesenteric  glands. 

In  cases  of  this  affection,  those  vague  indications  of  decaying  health 
which  characterise  the  early  stages  of  the  tuberculous  cachexia  often 
precede  any  symptom  of  special  disorder  of  the  abdominal  viscera. 
But  this  is  not  always  the  case ;  for  in  some  instances  the  child  begins, 
without  any  previous  indisposition,  to  complain  of  occasional  pains  in 
the  abdomen,  which  last  but  for  a  moment,  and  which  cause  the  less 
anxiety,  from  the  appetite  being  good,  the  bowels  regular,  and  the 
general  cheerfulness  undisturbed.  In  the  course  of  a  short  time,  how- 
ever, the  appetite  fails,  or  becomes  capricious;  the  bowels  begin  to  act 
irregularly,  being  alternately  constipated  and  relaxed ,  while  the 
motions,  always  abundant,  are  usually  unnatural  in  character, — dark, 


r 


SYxMPTOMS   AND   COURSE   OP   TUBERCULAR   PERITONITIS.  411 

loose,  and  slimy.  The  child  now  grows  restless  and  feverish  at  night, 
its  thirst  is  considerable,  and  the  abdominal  pain  becomes  both  more 
severe  and  more  frequent  in  its  recurrence.  Sometimes  the  stomach 
grows  very  irritable,  and  the  food  taken  is  occasionally  vomited  ;  but  this 
symptom  is  often  absent ;  while  the  tongue,  throughout  the  early  stages 
of  the  affection,  continues  for  the  most  part  clean  and  moist,  and  deviates 
but  little  from  its  appearance  in  health.  The  symptoms  just  enume- 
rated seldom  continue  long  without  being  accompanied  with  a  marked 
change  in  the  size  of  the  abdomen ;  and  sometimes  the  alteration  in 
the  abdomen  takes  place  rather  suddenly,  and  is  one  of  the  earliest 
signs  of  the  affection  from  which  the  child  is  suffering.  The  abdomen 
becomes  large,  tense,  and  tympanitic,  while  its  parietes  often  seem 
glued  to  the  subjacent  viscera ;  and  that  manipulation  which  causes  no 
discomfort,  even  when  practised  somewhat  roughly  on  the  big  abdomen 
of  a  rickety  child,  is  sure  to  occasion  uneasiness,  often  even  considerable 
pain,  when  tried  with  ever  so  much  gentleness  in  the  child  suffering 
from  chronic  peritonitis. 

In  this,  as  in  other  forms  of  tubercular  disease,  the  progress  from 
bad  to  worse  seldom  goes  on  uninterruptedly.  Pauses  take  place  in 
its  course,  though  each  time  they  become  shorter ;  and  signs  of  amend- 
ment now  and  then  appear, — but  they,  too,  promise  less  and  less  with 
each  return.  The  child  loses  flesh;  the  face  grows  pale,  and  sallow,  and 
anxious  ;  the  skin  becomes  habitually  dry,  and  hotter  than  natural,  and 
the  pulse  is  permanently  accelerated.  The  abdomen  does  not  grow 
progressively  larger,  but  it  becomes  more  and  more  tense,  although  this 
tension  varies  without  any  evident  cause,  and  sometimes  disappears  for 
a  day  or  two,\to  return  again  as  causelessly  as  it  disappeared.  When 
the  tension  is  diminished,  the  abdomen  yields  a  solid  and  doughy  sen- 
sation, and  the  union  between  the  contents  of  the  abdomen  and  the 
abdominal  walls  becomes  very  perceptible.  The  superficial  abdominal 
veins  now  become  enlarged  in  many  instances,  and  the  skin  grows 
rough,  desquamates,  and  looks  as  if  it  were  dirty.  The  pain  in  the 
bowels  retains  the  same  colicky  character  as  before,  but  it  returns  very 
frequently,  and  is  sometimes  exceedingly  severe,  while  the  child  is 
never  free  from  a  sense  of  uneasiness.  The  tenderness  of  the  abdomen, 
however,  but  seldom  increases  in  proportion  to  the  increase  of  pain. 
The  bowels  are  in  general  habitually  relaxed,  though  the  degree  of  the 
diarrhoea,  as  well  as  the  severity  of  the  abdominal  pain,  vary  much  in 
different  cases.  As  the  disease  advances,  the  child  becomes  confined 
to  bed,  and  is  at  length  reduced  to  a  state  of  extreme  weakness  and 
emaciation.  Death  is  often  hastened  by  the  concomitant  affection  of 
the  lungs  ;  but  should  this  not  be  the  case,  the  patient  may  continue 
for  many  weeks  in  the  same  condition,  till  life  is  destroyed,  after  a  day 
or  two  of  increased  suffering,  by  some  renewed  attack  of  peritoneal 
inflammation. 

Such,  now,  is  the  ordinary  course  of  tubercular  peritonitis ;  but  just 
as  it  would  not  be  possible  to  draw  a  picture  of  pulmonary  phthisis 
which  should  represent  with  perfect  accuracy  every  case  of  the  disease, 
so  it  is  with  our  attempt  to  delineate  the  features  of  this  malady.  Its 
main  diversities,  of  which  the  differences  in  the  appearances  found  after 


412  COURSE   OF   TUBERCULAR  PERITONITIS. 

death  are  far  from  affording  a  satisfactory  explanation,  consist  in  the 
various  degrees  in  which  pain  is  experienced,  in  the  rapidity  in  the 
course  of  the  affection,  and  in  the  alternation  of  constipation  with  diar- 
rhoea, or  sometimes  in  the  complete  substitution  of  the  one  condition  for 
the  other.  One  form  of  tubercular  peritonitis,  in  which  its  early  stages 
are  very  likely  to  be  unnoticed,  is  that  which  it  assumes  when  it  super- 
venes upon  one  of  the  eruptive  fevers — usually  upon  measles  :  the  diar- 
rhoea, the  feverishness,  the  loss  of  flesh,  are  regarded  merely  as  attend- 
ants upon  a  tardy  convalescence;  the  abdominal  pain,  probably  by  no 
means  severe,  is  supposed  to  be  of  little  moment ;  and  the  abiding  ten- 
derness is  altogether  overlooked.  The  chief  safeguard  against  this  error 
is  found  in  our  being  fully  alive  to  the  possibility  of  the  danger,  and  in 
the  most  sedulous  watching  of  every  child  whose  convalescence  is  tedious. 
In  other  instances  the  disease  sets  in  with  a  degree  of  febrile  disturbance 
which  throws  the  abdominal  affection  into  the  background,  and  the  case 
is  put  down  as  one  of  remittent  fever ;  a  mistake  from  which,  however, 
any  one  may  be  preserved  by  noting  that  the  pulse  is  less  frequent,  the 
heat  of  skin  less  intense ;  that  delirium  is  absent,  that  the  abdominal 
tenderness  is  more  general,  the  pain  usually  more  severe,  and  the  abdo- 
men more  tense.  Another  class  of  symptoms  which  should  excite  our 
suspicion  are  those  which  are  sometimes  presented  by  children  who, 
having  suffered  from  dyspepsia,  become  liable  to  occasional  attacks  of 
colic  and  constipation,  the  severity  of  the  pain  being  out  of  proportion 
to  the  duration  of  the  previous  constipation  ;  the  effect  of  purgatives  in 
inducing  action  of  the  bowels  being  uncertain,  and  the  relief  which  fol- 
lows their  operation  neither  immediate  nor  complete.  Lastly,  the  disease 
is  sometimes  observed  attended  by  scarcely  any  pain :  the  child  grows 
pale  and  thin,  and  has  occasional  diarrhoea,  but  makes  no  complaint  of 
pain,  or  at  most  of  nothing  beyond  a  sense  of  stuffing  and  fulness  of 
the  belly;  but  emaciation  goes  on,  perhaps,  rapidly;  the  diarrhoea 
becomes  habitual,  and  medicine  loses  much  of  its  control  over  it ;  the 
strength  fails,  and  the  little  one  dies,  worn  out  and  weary,  but  quietly 
and  without  pain.  It  would  be  easy,  but  I  do  not  think  it  necessary, 
to  relate  a  history  illustrative  of  each  of  these  varieties  of  the  disease; 
they  would  each  point  to  the  same  moral — that,  under  all  modifications 
of  symptoms,  when  a  child  loses  flesh,  and  has  in  conjunction  with  that 
emaciation,  abiding,  even  though  but  slight,  tenderness  of  the  abdomen 
on  pressure,  you  are  to  suspect  the  existence  of  tubercular  peritonitis. 
Some  of  you  have  probably  been  struck  by  the  many  points  of  resem- 
blance between  the  symptoms  that  have  just  been  described,  and  those 
which  are  often  enumerated  as  characteristic  of  mesenteric  disease. 
Nor  is  it  at  all  surprising  that  a  very  close  analogy  should  subsist 
between  chronic  peritonitis  and  tabes  mesenterial,  since  not  only  are 
both  affections  -the  results  of  the  tubercular  cachexia,  but  in  both  the 
abdominal  viscera  are  chiefly  involved  in  the  disease,  and  both  are  in 
consequence  characterised  by  a  remarkable  impairment  of  the  functions 
of  nutrition.  It  was  natural,  too,  that  in  former  times,  when  morbid 
anatomy  was  less  carefully  cultivated  than  at  present,  the  attention  of 
the  observer  should  have  been  chiefly  drawn  to  the  increased  size  and 
altered  structure  of  the  mesenteric  glands — appearances  which  must 


TABES   MESENTERICA — A  RARE  AFFECTION —  V    413 

have  been  often  discovered  on  an  examination  of  the  bodies  of  children 
who  had  died  after  a  slow  wasting  of  their  flesh,  attended  with  more  or 
less  enlargement  of  the  abdomen  and  disturbance  of  the  bowels.  The 
physiology  of  those  days,  too,  knew  of  no  means  whereby  the  absorption 
of  the  chyle  could  be  effected  except  through  the  medium  of  the  mesen- 
teric glands;  and  the  coarse  appliances  which  then  subserved  the  pur- 
poses of  anatomical  investigation  did  not  suffice  to  show  that,  even  when 
these  glands  outwardly  present  a  considerable  degree  of  tuberculization, 
their  lymphatics  in  many  instances  are  still  pervious. 

We  know  that  the  nutrition  of  children  is  often  much  impaired  from 
other  causes  besides  tubercular  disease ;  and  that,  when  the  digestive 
organs  perform  their  functions  ill,  nothing  is  more  common  than  for  the 
abdomen  greatly  to  exceed  its  natural  size.  Our  predecessors  had 
observed  similar  facts ;  but,  from  the  imperfection  of  their  physiological 
knowledge,  they  drew  from  them  erroneous  conclusions.  Disease  of  the 
mesenteric  glands  was  in  their  eyes  the  almost  exclusive  cause  of  the 
atrophy  of  children,  and  a  preternatural  enlargement  of  the  belly  was 
looked  upon  by  them  as  an  almost  infallible  sign  that  such  disease  had 
already  begun.  Tabes  mesenterica  was  consequently  regarded  as  a  very 
common  affection ;  and  though  its  frequency  is  now  well  known  to  have 
been  much  overrated,  yet  the  appearance  of  those  symptoms  that  were 
once  supposed  to  be  characteristic  of  it,  still  excites  much  needless 
alarm  among  non-professional  persons. 

The  mere  presence  of  tubercle  in  the  mesentery  is,  it  must  be  owned, 
of  very  common  occurrence,  since  MM.  Rilliet  and  Barthez  met  with  it 
in  nearly  half  of  all  the  children  in  whom  that  morbid  deposit  existed 
in  some  or  o^ier  of  the  viscera.  But  though  the  existence  of  tubercle 
in  the  glands  be  thus  frequent,  its  presence  in  any  considerable  quantity 
is  extremely  rare,  since,  according  to  the  same  authorities,  it  was  found 
in  abundance,  only  in  one  out  of  every  sixteen  children,  some  of  whose 
organs  contained  tubercle. 

The  general  character  of  tuberculous  mesenteric  glands  is  much  the 
same  with  that  of  tuberculous  bronchial  glands,,  but  the  former  are 
usually  surrounded  by  a  more  delicate  cyst ;  and  although  their  size 
seldom  exceeds  that  of  a  chesnut,  yet  they  occasionally  undergo  a 
degree  of  development  which  far  exceeds  that  of  tuberculous  bronchial 
glands,  and  three  or  four  of  them  coalescing  together,  sometimes  form 
a  mass  as  big  as  the  fist,  or  even  bigger. 

The  effects  produced  even  by  an  advanced  degree  of  tuberculization 
of  the  mesenteric  glands  are  smaller  than  might  be  anticipated,  and 
much  smaller  than  those  which  result  from  a  considerably  less  amount 
of  disease  of  the  bronchial  glands.  Nor  will  this  at  all  surprise  us,  if 
we  bear  in  mind  the  difference  between  their  anatomical  relations. 
The  bronchial  glands  are  not  merely  situated  in  a  cavity  which  is 
bounded  by  comparatively  unyielding  parietes,  but  the  viscera  with 
which  they  are  in  contact  are  solid  and  resisting,  and  they  are,  more- 
over, adherent  to  the  trachea  and  the  larger  air-tubes,  so  that  any 
increase  of  their  size  is  sure  to'  produce  compression  of  parts  whose 
functions  are  of  vital  importance.  The  mesenteric  glands,  on  the  con- 
trary, are  contained  in  a  cavity  whose  yielding  walls  allow  them  to 


414  ITS   SYMPTOMS. 

increase  readily  in  size,  while  the  loose  attachments  of  the  mesentery 
still  further  permit  them  to  attain  even  to  considerable  dimensions, 
"without  pressing  upon  any  viscus  ;  so  that  it  is  an  exceedingly  unusual 
occurrence  for  them  to  cause  the  perforation  of  any  part  of  the  intes- 
tines, or  even  for  them  to  contract  adhesions  to  their  exterior. 

To  these  causes  it  must  be  attributed  that  there  is  no  symptom 
pathognomonic  of  tubercle  of  the  mesenteric  glands,  except  their  being 
perceptible  through  the  abdominal  parietes.  This,  however,  they  never 
are  during  the  early  stage  of  the  affection  ;  and  though  on  one  or  two 
occasions  I  have  felt  a  tumor  in  the  abdomen,  which,  from  its  being 
associated  with  the  evidences  of  tuberculous  disease  in  other  organs,  I 
have  been  led  to  attribute  to  the  enlarged  mesenteric  glands,  yet  in 
these  cases,  I  have  not  had  the  opportunity  of  confirming  the  diagnosis 
by  an  examination  after  death.  There  can,  however,  be  no  doubt  but 
that  they  do  become  perceptible  through  the  abdominal  walls,  though 
at  a  season  when,  their  cure  being  hopeless,  little  practical  use  can  be 
made  of  the  certainty  of  our  diagnosis.  In  its  earlier  stages  no 
symptoms  at  all  are  present,  or  only  the  indications  of  that  general 
tuberculous  disease  of  which  the  affection  of  the  mesentery  is  usually 
but  a  subordinate  part.  At  a  later  period,  when  the  disorder  of  the 
digestive  organs  attracts  attention,  the  symptoms  are  generally  much 
the  same  with  those  of  chronic  peritonitis,  save  that  if  the  peritoneum 
be  free  from  disease,  the  abdomen  is  in  most  cases  both  less  tense  and 
less  tender. 

I  the  less  regret  that  so  little  time  remains  for  the  consideration  of 
the  treatment  of  chronic  peritonitis  and  of  tabes  mesenterica,  since  the 
subject  may  be  dismissed  in  a  few  words.  In  each  of  these  affections 
two  periods  may  be  distinguished.  During  the  first,  while  our  diagnosis 
is  still  uncertain,  general  principles  guide  our  conduct,  and  lead  us  to 
subject  the  child  to  the  same  dietetic  and  hygienic  management  as  we 
should  adopt  if  we  feared  the  approach  of  any  other  form  of  phthisis. 
In  the  second,  the  advancing  mischief  has  removed  all  doubt  from  our 
minds,  but  at  the  same  time  has  chased  all  hope  from  our  spirits  ;  and 
we  now  minister  to  symptoms  as  they  arise,  and  try  to  mitigate  sufferings 
which  we  cannot  cure. 

The  dyspeptic  symptoms,  the  unhealthy  appearance  of  the  evacua- 
tions, and  the  frequency  with  which  diarrhoea  occurs,  enforce  the 
necessity  for  the  diet  being  as  mild  and  unstimulating  as  possible.  The 
abdominal  pain  which  is  experienced  in  tubercular  peritonitis  is  almost 
always  relieved  by  the  application  of  a  few  leeches;  but  even  local 
depletion  must  not  be  practised  without  absolute  necessity ;  and  in 
many  instances  a  large  poultice  to  the  abdomen,  frequently  renewed, 
will  remove  pain,  the  severity  of  which  had  at  first  seemed  to  call  for 
the  abstraction  of  blood.  Now  and  then,  however,  symptoms  of  acute 
peritonitis  come  on  in  children  who  have  manifested  previously  unmis- 
takeable  signs  of  tubercular  disease,  and  nevertheless  yield  to  free  local 
depletion,  and  the  administration  of  mercury.  I  would  therefore 
advise  you  not  to  allow  any  notion,  how  well  founded  soever,  of  the 
probable  connection  of  the  symptoms  with  tubercular  disease,  to  betray 
you  during  the  presence  of  acute  symptoms  into  an  inert  course  of 


TREATMENT   OF   TUBERCULAR   PERITONITIS.  415 

treatment ;  nor,  I  may  add,  into  the  too  positive  expression  of  a 
gloomy  prognosis.  Still  these  are  exceptional  cases  ;  and  our  treat- 
ment in  the  majority  of  instances  is  confined  to  relieving  the  more 
urgent  symptoms.  Next  in  importance  to  the  pain,  or  sometimes  even 
more  important,  is  the  diarrhoea,  which  we  must  try  by  all  means  to 
keep  in  check  ;  for  which  purpose  few  astringents  are  better  than  the 
logwood  and  catechu  mixture  mentioned  in  the  last  lecture.  Sulphate 
of  iron  and  opium,  in  the  form  either  of  pills  or  mixture,  may  be  used 
if  the  diarrhoea  be  very  obstinate,  though  we  may  be  compelled  to 
abandon  their  use,  from  finding  that  they  add  to  the  fever,  and  thus 
aggravate  the  patient's  symptoms  ;  but  I  have  not  observed  the  mere 
suppression  of  the  diarrhoea  by  astringents  to  be  followed  by  any 
exacerbation  of  the  other  abdominal  symptoms.  Astringents,  however, 
are  far  from  being  the  only  remedies  to  be  employed ;  but  mercurials 
in  a  mild  form,  and  continued  for  a  long  period,  have  often  seemed  to 
be  of  much  service.  When  the  tenderness  of  the  abdomen  has  been 
sufficiently  relieved  to  admit  of  it,  I  generally  direct  the  use  of  a  lini- 
ment twice  a  day,  consisting  of  the  Linimentum  Hydrargyri,  soap 
liniment,  and  olive  oil,  in  equal  parts,  which  has  seemed  useful  as  a 
counter-irritant  even  independent  of  the  mercury  which  enters  into  its 
composition.  Besides  this  I  usually  give  equal  parts  of  the  Hydr.  c. 
Creta  and  Dover's  powder  once  or  twice  a  day.  The  Dover's  powder 
prevents  the  mercurial  from  irritating  the  bowels,  and  also  allays  the 
restlessness  and  feverishness  at  night — an  end  to  which  the  use  of  the 
tepid  bath  every  evening  likewise  conduces,  often  in  an  eminent  degree. 
The  comfort  of  the  child  is  frequently  much  promoted  by  wearing  a  well- 
adapted  flaniicl  bandage  over  the  abdomen  both  by  night  as  well  as  by 
day ;  and  the  support  this  affords  may  be  increased  with  advantage  by 
a  piece  of  thin  whalebone  at  either  side. 

If  diarrhoea  be  absent,  or  if,  though  it  be  present  in  a  slight  degree, 
the  skin  be  very  hot  and  dry,  and  the  child  very  thirsty  and  feverish, 
the  tepid  bath,  the  mercurial  with  Dover's  powder,  and  small  doses  of 
liquor  potassae  and  ipecacuanha,  are  the  remedies  on  which  I  chiefly 
rely,  and  to  this  the  extract  of  dandelion  may  often  be  added  with 
advantage.  If  it  seem  likely  that  a  mild  tonic  will  be  borne,  a  mixture 
containing  the  extract  of  dandelion,  extract  of  sarsaparilla,  and  sesqui- 
carbonate  of  soda,1  may  be  given ;  or  the  liquor  cinchonae  or  the  infu- 

(No.  33.) 
1  R  Extracti  Taraxaci,  ^ij. 
Sodse  Sesquicarbonatis,  gj. 
Extr.  Sarzse,  giv. 
Syr.  Aurantii,  ^iv. 

Decoct.  Sarzse  Co.  ^vss.     M.     gvj.  ter  die  e  lacte. 
For  a  child  four  years  old. 

sion  of  calumba  may  be  employed  for  the  same  purpose.  It  is  only 
with  much  caution  that  we  can  administer  chalybeates  in  these  cases, 
and  after  having  found  that  the  milder  vegetable  tonics  are  well  borne. 
The  ferro-citrate  of  quinine,  or  the  citrate  of  iron,  are  the  preparations 


416  INTESTINAL  WORMS. 

which  it  will  generally  be  desirable  to  employ  in  the  first  instance,  and 
even  their  effect  should  be  watched  attentively.  When  well  borne,  the 
cod-liver  oil  is,  I  think,  more  useful  in  this  than  in  any  other  form  of 
the  tuberculous  cachexia  in  early  life.  The  cases  in  which  it  causes 
nausea  or  diarrhoea  are  comparatively  few,  and  its  effects  in  fattening 
children  who  were  greatly  emaciated  are  sometimes  very  remarkable. 
In  conclusion,  I  need  hardly  mention  the  importance  of  change  of  air, 
and  the  benefits  likely  to  result  from  a  sojourn  on  the  sea-coast;  for 
you  know  how  much  more  powerful  nature's  remedies  are  in  diseases  of 
this  kind  than  the  remedies  of  man's  devising. 


LECTUKE  XXXV. 

Intestinal  Worms — their  varieties,  symptoms,  and  treatment. 

Diseases  of  the  Urinary  Organs — Inflammation  of  the  kidneys — Albuminous  nephritis 
— generally  follows  one  of  the  eruptive  fevers,  oftenest  scarlatina — its  symptoms — 
condition  of  the  urine — appearances  after  death — essential  nature  of  the  changes  in 
the  kidneys. — Treatment. 

Calculous  disorders — frequent  in  early  life — deposits  in  the  urine  in  childhood  almost 
always  consist  of  the  lithates. — Other  causes  of  dysuria  besides  gravel  and  calculus. — 
Treatment  of  dysuria  in  early  life — Lithic  acid  deposits  connected  with  chronic  rheu- 
matism in  children — symptoms  of  ill  health  associated  with  them — importance  of  not 
overlooking  them. 

Diabetes — true  saccharine  diabetes  very  rare  in  early  life — simple  diuresis  less  uncom- 
mon— symptoms  of  disordered  health  that  attend  both  affections. — Treatment. 

Incontinence  of  urine — circumstances  under  which  it  occurs. — Treatment. 

Our  study  of  the  diseases  of  the  digestive  organs  would  be  incom- 
plete if  we  took  no  notice  of  those  parasitic  animals  which  frequently 
inhabit  the  alimentary  canal  in  children.  It  will  not,  indeed,  be  neces- 
sary to  say  much  respecting  them;  for  we  know  that  the  older  medical 
writers  greatly  overrated  their  frequency  and  importance,  when  they 
saw  the  proofs  of  their  existence  in  almost  every  variety  of  gastric  and 
intestinal  disorder,  and  even  attributed  to  their  presence  many  forms 
of  serious  disturbance  of  the  nervous  system.  Still,  they  are  in  many 
instances  the  occasion  of  considerable  discomfort ;  they  often  aggravate, 
and  sometimes  even  give  rise  to,  disorder  of  the  digestive  organs,  while 
now  and  then  the  irritation  excited  by  their  presence  being  propagated 
to  the  spinal  cord,  produces  convulsions  or  other  formidable  nervous 
symptoms. 

Although  intestinal  worms  are  much  more  common  in  early  life  than 
in  adult  age,  yet  no  species  of  them  is  peculiar  to  the  child,  but  they 
belong  to  one  or  other  of  the  five  sorts  ordinarily  met  with  in  the  grown 
person. 

The  ascaris  vermicularis,  or  small  thread-worm,  which  lives  princi- 
pally in  the  rectum,  is  by  far  the  most  common  of  all  these  entozoa, 
and  is  very  troublesome,  from  the  local  irritation  which  it  excites.  The 
long  thread-worm,  the  tricocephalus  dispar,  appears  much  less  fre- 
quently in  the  evacuations:  it  inhabits  the  upper  ends  of  the  large 


SYMPTOMS   OF   INTESTINAL   WORMS.  417 

intestines,  and  in  some  cases  coexists  with  the  presence  of  ascarides  in 
the  rectum.  When  it  is  present  alone,  I  am  not  aware  that  it  gives  rise 
to  any  unpleasant  symptoms.  The  ascaris  lumbricoides  is  of  much  less 
common  occurrence  than  the  small  thread-worm,  though  observed  more 
frequently  than  the  tricocephalus :  it  dwells  in  the  small  intestines,  and 
sometimes,  entering  the  stomach,  is  rejected  by  vomiting.  Occasionally 
only  one  of  these  worms  is  present,  and  though  there  are  oftener  several, 
yet  it  is  but  seldom  that  they  exist  in  the  child  in  very  considerable 
numbers.  The  tape-worm,  of  which  there  are  two  kinds,  the  taenia 
solium  and  taenia  lata,  is  much  the  rarest  of  these  entozoa  in  early  life, 
and  is  seldom  met  with  in  children  under  seven  years  of  age,  though 
once  or  twice  I  have  known  it  to  exist  in  infants  who  were  still  in  part 
nourished  at  the  breast. 

Various  symptoms  have  been  said  to  indicate  the  presence  of  worms 
in  the  intestines,  but  most  of  them  are  of  small  value :  and  nothing  short 
of  actually  seeing  the  worms  can  be  regarded  as  affording  conclusive 
evidence  of  their  existence.  No  one  who  is  at  all  familiar  with 
the  disorders  of  early  life  will  be  disposed  to  attach  much  weight  to 
symptoms,  such  as  the  altered  hue  of  the  face,  the  appearance  of  a  livid 
circle  around  the  eyes,  the  loss  of  appetite,  or  its  becoming  irregular  or 
capricious.  Many  causes  besides  the  presence  of  worms  give  rise  to  a 
tumid  state  of  the  abdomen,  to  colicky  pains,  and  to  occasional  sickness 
and  vomiting ;  and  itching  of  the  nose  or  anus,  though  often  present 
when  the  intestinal  canal  is  infested  with  worms,  yet  is  sometimes  the 
occasion  of  much  annoyance  independently  of  their  existence.  An 
irregular  or  intermittent  pulse,  widely  dilated  pupils,  occasional  drowsi- 
ness, with  uneasy  rest  at  night,  and  starting  during  sleep,  are  evidences 
of  disturbance  of  the  nervous  system,  but  do  not  specially  indicate  the 
presence  of  wrorms  as  the  cause  of  such  irritation. 

In  any  case  however,  where  symptoms  such  as  those  above  mentioned 
make  their  appearance,  and,  though  fluctuating  in  severity,  continue  for 
weeks  together,  there  exists,  in  the  absence  of  any  obvious  cause  of 
nervous  irritation,  reasonable  grounds  for  suspecting  the  presence  of 
worms ;  and  the  evacuations  should  be  examined,  in  order  to  ascertain 
whether  or  no  that  suspicion  is  well  founded.  Even  though  for  a  season 
none  should  be  discovered,  yet  fortunately  the  treatment  which  the 
general  symptoms  would  lead  us  to  adopt  will  be  in  great  measure  such 
as,  if  worms  exist,  will  prove  most  efficacious  in  producing  their  expul- 
sion. The  capricious  appetite  will  induce  us  to  regulate  the  diet  with 
care ;  the  disordered  and  generally  constipated  state  of  the  bowels  will 
lead  to  the  employment  of  alteratives,  and  to  the  occasional  administra- 
tion of  brisk  cathartics ;  while  the  absence  of  febrile  symptoms  will 
probably  seem  to  warrant  the  employment  of  some  of  the  preparations 
of  iron.  These  remedies  will  in  many  instances  not  have  been  continued 
long  before  the  appearance  of  worms  in  the  motions  encourages  us  to 
persevere  in  the  same  treatment.  The  combination  of  ferruginous 
preparations  with  active  purgatives  is  a  plan  especially  effective  in  cases 
where  the  lumbricoid  entozoa  are  present,  and  is  likewise  of  much  ser- 
vice in  getting  rid  of  the  ascarides  which  inhabit  the  rectum,  and  in 
preventing  their  reproduction.     The  latter  worms,  however,  need  to  be 

27 


418  TREATMENT   OF  INTESTINAL  WORMS. 

assailed  in  their  habitation ;  and,  from  the  circumstance  of  their  living  in 
the  lower  end  of  the  rectum,  this  is  a  sufficiently  easy  task.  Enemata  of 
lime-water  usually  answer  the  purpose  of  destroying  them ;  hut,  should 
they  fail,  the  addition  of  some  two  drachms  of  the  muriated  tincture 
of  iron  to  the  clyster  is  tolerably  sure  to  make  it  effective.  In  young 
children  these  ascarides  sometimes  not  merely  occasion  much  itching 
and  distressing  irritation  about  the  anus,  but  even  produce  a  trouble- 
some diarrhoea,  attended  with  considerable  tenesmus.  Under  such 
circumstances,  the  lime-water  should  be  administered  daily  for  two  or 
three  days  together ;  while,  at  the  same  time,  small  doses  of  the  castor- 
oil  mixture  every  six  or  eight  hours  will  soothe  the  irritation  of  the 
bowels.  In  female  children  these  ascarides  sometimes  creep  up  the 
vulva,  and  not  merely  cause  much  irritation  there,  but  excite  a  leucor- 
rhoeal  discharge,  which  ceases  on  the  expulsion  of  the  worms. 

The  alarming  symptoms  of  cerebral  disturbance  which  are  occasion- 
ally produced  by  worms  jn  the  intestinal  canal,  result  more  frequently 
from  the  presence  of  the  round  worm  than  of  other  varieties  of  these 
entozoa.  This,  however,  is  not  always  the  case ;  and  is  the  only 
instance  that  has  come  under  my  observation  in  which  the  occurrence 
of  serious  convulsions  seemed  clearly  traceable  to  the  presence  of 
worms  in  the  intestines,  the  small  thread-worms  were  the  cause  of  the 
symptoms.  Apart  from  the  knowledge  which  we  have  in  many  of  these 
cases  that  the  child  had  been  previously  afflicted  with  worms,  there  is 
nothing  in  the  symptoms  which  could  enable  us  at  once  to  distinguish 
between  convulsions  from  this  cause  and  those  which  result  from  some 
other  source  of  irritation  of  the  nervous  system.  In  most  instances, 
however,  the  child  has  passed  worms  frequently  before  the  cerebral 
symptoms  made  their  appearance,  and  not  improbably  was  under  treat- 
ment for  the  destruction  of  those  parasites  at  the  time  when  the 
nervous  symptoms  supervened.  Even  though  this  be  not  the  case,  the 
constipated  state  of  the  bowels  which  is  almost  sure  to  have  preceded  the 
occurrence  of  the  convulsions,  indicates  the  employment  of  active  pur- 
gatives— remedies  which  in  most  instances  remove  together  these 
symptoms  and  their  cause,  although  convulsions  apparently  induced 
by  the  presence  of  worms  have  sometimes  had  a  fatal  termination. 

The  tsenia  is,  as  was  stated,  much  less  common  in  childhood  than 
after  puberty ;  and  in  the  few  cases  in  which  I  have  met  with  it  during 
early  life,  I  have  been  reluctant  to  try,  until  after  the  fruitless  employ- 
ment of  other  medicines,  that  heroic  remedy,  turpentine  and  castor-oil, 
which  is  so  serviceable  in  procuring  the  expulsion  of  tape-worm  in  the 
adult.  When  I  have  used  it  in  the  child,  it  has  always  proved  effica- 
cious in  bringing  away  large  quantities  of  the  worm,  but  one  seldom 
has  dispensary  patients  sufficiently  long  under  observation  to  feel  sure 
that  the  apparent  cure  of  such  a  disease  has  been  permanent.  I  have 
been  accustomed  to  employ  the  decoction  of  the  bark  of  the  pomegranate 
root  in  doses  of  an  ounce  three  times  a  day  for  a  child  of  seven  years 
old,  interrupting  its  administration  twice  in  the  week,  in  order  to  give 
a  purgative  of  scammony  and  calomel.  Under  this  plan,  pursued  for 
several  weeks  together,  large  quantities  of  the  worm  have  been  voided, 
and  the  children  have  appeared  entirely  freed  from  this  very  trouble- 


DISEASES   OF   THE   URINARY   ORGANS. — NEPHRITIS.  419 

some  parasite.  It  is  undoubtedly  more  certainly  and  speedily  effica- 
cious when  given  every  hour  for  four  or  five  successive  hours,  as 
recommended  by  Mr.  Breton,1  who  first  brought  the  remedy  into  notice 
in  this  country  ;  but  I  have  found  an  unavoidable  difficulty  in  any 
attempt  so  to  administer  it,  from  the  natural  repugnance  of  children 
to  take  medicine,  especially  when  in  a  bulky  form,  or  when  its  taste 
is  unpleasant.  I  have  had  no  opportunity  of  employing  the  new  remedy 
Kousso,  but  testimony  appears  to  be  unanimous  in  its  favour,  as  more 
efficacious  than  any  other  anthelmintic  which  we  possess. 

Closely  connected  with  the  disorders  of  the  digestive  organs  are 
those  affections  to  which  the  urinary  apparatus  is  liable.  Unfortu- 
nately, special  difficulties  attend  their  investigation  in  early  life,  and 
difficulties  which  it  is  least  easy  to  overcome  in  dispensary  practice  : 
hence  the  information  which  it  is  in  my  power  to  give  you  with  refe- 
rence to  these  diseases  is  less  complete  than  I  could  have  desired. 

Nephritis,  or  acute  inflammation  of  the  substance  of  the  kidney,  is 
exceedingly  rare,  as  an  idiopathic  affection,  in  early  life.  MM.  Rilliet 
and  Barthez,2  decline  attempting  to  give  any  description  of  its  symp- 
toms, on  account  of  the  very  few  instances  of  it  that  have  come  under 
their  observation,  although  they  refer  to  some  cases  in  which  the  con- 
gested, swollen,  and  indurated  state  of  the  kidneys  after  death  seemed 
to  indicate  that  those  organs  had  been  the  seat  of  acute  inflammatory 
action.  M.  Bayer3  relates  an  instance  or  two  where  the  presence  of 
purulent  deposits  in  the  kidneys  of  infants  a  few  clays  old  gave  positive 
evidence  of  their  inflammation ;  but  no  symptoms  observed  during  the 
lifetime  of  these  children  had  called  attention  to  their  urinary  organs. 
He  mentions  it,\ moreover,  as  a  disease  of  very  unusual  occurrence  in 
early  life,  and  adds,  that  though  he  has  seen  cystitis  follow  the  appli- 
cation of  a  blister  in  early  life,  yet  in  those  cases  there  was  no  sign  of 
the  irritation  having  extended  to  the  kidneys. 

Albuminous  nephritis,  or  that  form  of  inflammation  of  the  kidney 
which  is  usually  met  with  in  connection  with  general  dropsy,  is  rather 
less  uncommon  as  a  primary  disease,  though  in  by  far  the  greater 
number  of  cases  it  is  met  with  as  a  sequela  of  one  of  the  eruptive 
fevers,  generally  of  scarlatina.  It  is  under  these  latter  circumstances 
only  that  it  has  presented  itself  to  my  notice,  and  the  description 
which  I  will  endeavour  to  give  you  of  it  applies  to  the  characters  that 
it  then  assumes.  It  sometimes  sets  in  with  symptoms  of  considerable 
severity,  but  even  then  it  has  a  great  tendency  to  pass  into  a  chronic 
state,  while  in  by  far  the  majority  of  cases  its  attack  is  gradual,  and  its 
advance  is  slow.  The  dropsical  symptoms  by  which  it  is  almost 
always  attended,  generally  show  themselves  within  a  fortnight  or  three 
weeks  from  the  appearance  of  the  rash  ;  the  face,  hands,  and  feet, 
being  affected  in  succession,  and  fluid  being  likewise  sometimes  effused 
into  the  cavity  of  the  abdomen.  The  dropsical  symptoms  are  generally 
preceded  for  a  day  or  two  by  the  indications  of  constitutional  distur 

1  Medico  Chirurgical  Transactions,  vol.  xi.  p.  301. 

2  Op.  cit.  vol.  i.  chap.  xvi. 

3  Traite  des  Maladies  des  Reins,  8to.  vol.  i.  p.  417.     Paris,  1839. 


420  SYMPTOMS   OF   ALBUMINOUS   NEPHRITIS   AND    SCARLATINA. 

bance.  The  child  who  had  passed  through  the  attack  of  fever  perhaps 
with  less  than  the  average  amount  of  suffering,  and  who  for  a  few  days 
had  seemed  rapidly  advancing  to  convalescence,  begins  to  droop,  grows 
languid,  feverish,  and  restless.  The  skin  becomes  dry  and  hot ;  the 
process  of  desquamation  is  arrested  while  still  incomplete  ;  the  appe- 
tite is  lost,  though  the  thirst  is  often  considerable  ;  the  bowels  become 
constipated,  and  the  urine  diminished  in  quantity,  although  the  desire 
for  voiding  it  is  very  frequent.  After  these  signs  of  interrupted  con- 
valescence have  continued  for  two  or  three  days,  or  even  longer,  the 
face  becomes  slightly  swollen,  a  puffiness  appearing  about  the  eyelids 
in  the  morning,  which  probably  disappears  later  in  the  day  ;  so  that 
in  many  instances  the  attention  of  the  parents  is  not  particularly 
directed  to  the  child's  condition  until  oedema  has  extended  to  the  hands 
and  feet.  The  degree  of  anasarca  varies  much  in  different  cases,  and 
likewise  fluctuates  at  different  periods  in  the  same  patient.  Usually, 
though  not  invariably,  there  is  a  distinct  relation  between  the  degree 
of  swelling  and  the  severity  of  the  general  symptoms ;  and  few  cases 
terminate  fatally  in  which  there  is  not  considerable  serous  effusion 
into  the  different  cavities  of  the  body.  In  very  mild  cases  the  febrile 
disturbance  is  inconsiderable,  the  anasarca  slight,  and  confined  to  the 
face ;  and  after  a  few  days  of  poorliness,  the  kidneys  resume  their 
proper  functions,  the  anasarca  disappears,  and  the  child's  health  returns. 
In  severe  cases  the  symptoms  persist  for  a  longer  time,  and  complaints 
of  pain  in  the  back,  and  evident  tenderness  in  the  lumbar  region,  are 
usually  associated  with  them,  while  the  swelling  extends  to  the  cellular 
tissue  of  most  parts  of  the  body ;  but  unless  some  complication  should 
exist,  improvement  generally  becomes  apparent  in  the  course  of  a 
week  or  ten  days,  and  recovery  takes  place  slowly.  In  the  worst 
cases,  the  swelling,  after  having  undergone  many  apparently  cause- 
less fluctuations,  becomes  extreme,  as  well  as  universal;  the  features 
are  disfigured  by  the  dropsy,  the  legs  greatly  swollen,  and  the  abdo- 
minal parietes  much  infiltrated,  while  the  skin  remains  dry  and  hot. 
The  quantity  of  water  voided  is  very  small  indeed,  and  the  pain  in 
the  back  is  often  very  severe.  The  chief  suffering,  however,  is  referred 
to  the  chest ;  the  respiration  is  laboured  and  accelerated,  and  the  child 
is  frequently  unable  to  assume  the  recumbent  posture,  and  is  moreover 
distressed  by  a  frequent,  short,  hacking  cough.  Under  these  circum- 
stances, life  is  sometimes  prolonged  for  several  days,  though  in  a  state 
of  extreme  suffering,  remedies  proving  unable  either  to  increase  the 
action  of  the  kidneys,  or  to  relieve  the  dropsy.  Death  is  sometimes 
preceded  by  a  sudden  aggravation  of  the  signs  of  disorder  of  the  respi- 
ratory organs,  which  assumes  all  the  painful  characteristics  of  oedema 
of  the  lungs  ;  and  in  other  cases  a  comatose  condition  comes  on,  such 
as  often  precedes  death  from  Bright's  disease  in  the  adult.  Sometimes 
a  temporary  improvement  takes  place,  the  anasarca  abates,  and  the 
kidneys  resume  their  functions,  but  the  patient  dies  not  long  afterwards 
from  the  effects  of  the  pleurisy  or  pericarditis,  which  had  come  on 
almost  unnoticed  during  the  acute  stage  of  the  affection. 

These  symptoms  of  constitutional  disturbance,  which  you  recognize 
as   the   characteristics  of    inflammatory  dropsy,   are  associated  with 


CHANGES   IN   THE   URINE.  421 

changes  in  the  composition  of  the  urine,  as  well  as  with  a  diminution 
in  the  quantity  of  the  secretion.  In  the  milder  cases  it  is  transparent 
when  passed,  though  of  a  deeper  colour  than  natural,  and  becomes  turbid 
on  cooling,  when  it  deposites  a  more  or  less  abundant  precipitate.  It 
has  a  strong  acid  reaction,  somewhat  exceeds  the  usual  specific  gravity 
of  healthy  urine,  is  at  first  rendered  clear  by  the  application  of  heat,  but 
again  becomes  cloudy  as  the  albumen  which  it  contains  is  coagulated, 
and  falls  down  in  a  flocculent  precipitate.  If  the  attack  be  more 
severe,  the  urine,  which  is  very  scanty,  is  of  a  brown  or  smoke  colour, 
deep  red,  or  coffee-coloured,  and  throws  down  a  deposit  chiefly  of  a 
reddish-brown  colour  ;  which,  however,  does  not  entirely  disappear  when 
heated,  while  albumen  is  present  in  it  in  extreme  abundance.  An  exa- 
mination under  the  microscope  of  the  deposit  that  takes  place  sponta- 
neously in  the  urine  in  these  cases,  discovers  not  merely  crystals  of  the 
lithate  of  ammonia,  but  blood  globules,  often  very  little  altered,  mucus 
corpuscles,  and  epithelium  scales.  These  matters,  however,  disappear 
by  degrees  as  the  urine  regains  its  natural  appearance,  even  though  it 
may  still  be  shown  by  chemical  reagents  not  to  be  entirely  free  from 
albumen. 

In  cases  where  death  takes  place  during  the  progress  of  this  disease, 
if  the  dropsical  symptoms  had  not  been  very  severe,  and  the  child  had 
been  carried  off  less  by  them  than  by  some  sudden  cerebral  symptoms, 
or  some  intercurrent  serous  inflammation,  the  kidneys  appear  to  the 
naked  eye  no  otherwise  altered  than  in  being  generally  darker  and 
more  congested  than  natural.  In  severer  cases,  however,  in  which 
death  has  resulted  from  the  disease  itself,  and  not  from  any  casual  com- 
plication, the  capsule  of  the  kidneys  strips  off  more  easily  than  natural, 
and  their  surface  presents  a  pale  colour  and  a  mottled  appearance. 
On  a  section  being  made,  a  marked  contrast  is  observable  between  the 
pale,  fawn-coloured,  cortical  structure  of  the  organs,  and  their  deeply 
injected  tubular  part,  coupled  with  which  their  pelvis  and  infundibula 
generally  display  a  greatly  increased  vascularity. 

The  use  of  the  microscope  has  of  late  enabled  us  to  advance  a  step 
further  than  we  otherwise  could  have  done  towards  understanding  the 
pathology  of  this  disease.1  It  has  shown  us  that  the  morbid  process 
begins  in  the  cortical  parts  of  the  inflamed  kidney,  the  urinary  tubules 
of  which  are  stimulated  to  an  increased  production  of  their  epithelial 
lining,  or  even  to  a  pouring  out  of  solid  fibrinous  matter  into  their  cavi- 
ties. The  urine  carries  away  with  it  some  of  these  matters,  and  thus 
frees  the  tubules  for  a  time ;  but  as  their  contents  are  reproduced  in 
quantities  too  large  to  be  thus  eliminated,  some  of  the  tubules  become 
plugged  and  impervious,  sometimes  even  so  over-distended  that  they 
give  way,  and  are  completely  destroyed.  Nor  is  this  all,  but  the  capil- 
laries of  the  organ  necessarily  bear  a  part  in  the  mischief.  At  first, 
from  over  congestion,  they  become  dilated  and  varicose,  and  afterwards 

1  On  this  subject  it  is  almost  needless  to  refer  to  the  papers  of  Dr.  Johnson,  Mr. 
Busk,  and  Mr.  Toynbee,  in  vol.  xxix.  of  the  Medico  Chirurgical  Transactions,  or  to 
those  by  Dr.  Johnson  and  Mr.  Simon,  in  vol.  xxx.  ;  together  with  the  note  appended  to 
the  latter  volume  by  the  editors,  respecting  the  labours  of  continental  observers  in  this 
field  of  inquiry. 


422  CHANGES   IN   THE   KIDNEYS — PATHOLOGY  OP   THE   DISEASE. 

(in  part  probably  from  the  formation  of  fibrinous  clots  within  them,  in 
part  as  the  result  of  a  process  of  adhesive  inflammation),  they  become 
obstructed  or  even  obliterated.  Supposing  this  morbid  process  to  have 
gone  on  to  any  considerable  extent,  the  kidney  must  be  left  by  it  per- 
manently and  irreparably  injured ;  while  even  in  its  slighter  degrees  it 
must  for  a  time  seriously  disturb  the  functions  of  the  organ.  In  the 
earlier  stages  of  the  disease,  the  presence  of  albumen  in  the  urine  is  in 
part  due  to  the  actual  escape  of  blood  from  the  over-loaded  capillaries 
of  the  kidney,  in  part  to  the  temporary  suspension  of  its  functions.  If 
at  a  later  period,  when  the  urine  has  lost  its  preternaturally  deep  colour, 
and  has  regained  much  of  its  healthy  appearance,  albumen  should  still 
exist  in  any  quantity,  there  will  be  reason  for  apprehending  that  some 
abiding  injury  has  been  inflicted  on  the  organ. 

In  the  case  of  the  dropsy  that  succeeds  to  scarlatina,  although  the 
convalescence  is  often  very  tedious,  there  fortunately  does  not  appear 
to  be  much  tendency  to  the  production  of  any  serious  permanent  injury 
to  the  kidney.  The  danger  to  the  patient  in  the  acute  stage  of  the 
affection  is,  however,  often  very  considerable,  if  the  attack  be  severe ; 
for  the  function  of  the  kidney  is  almost  entirely  suspended,  while  at  the 
same  time  the  action  of  the  skin,  that  other  great  emunctory  of  the 
system,  is  completely  arrested.  Chemical  reagents  shew  that  the  blood 
which  circulates  through  the  vessels  is  laden  with  urea,  which  the  sys- 
tem, unable  to  eliminate  by  its  natural  outlets,  tries  to  get  rid  of  by 
pouring  it  out  abundantly  in  the  serous  effusions  that  take  place  into 
tne  different  cavities  of  the  body.  These  efforts  of  nature  to  relieve 
herself  not  only  prove  unsuccessful,  but  the  effused  fluid  often  seriously 
interferes  with  the  due  performance  of  their  functions  by  the  different 
viscera  ;  and  I  have  seen  several  instances  of  sudden  death  from  hydro- 
thorax  under  these  circumstances.  In  other  cases  inflammation  attacks 
the  pleura,  or  pericardium,  or  less  frequently  the  peritoneum  ;  while, 
even  though  these  secondary  affections  should  not  be  very  severe,  still 
the  continuance  of  life  is  not  compatible  with  the  circulation  through 
the  body  of  blood  loaded  with  urea. 

When  this  affection  occurs  as  a  sequela  of  scarlatina,  it  may  very  often 
be  traced  to  exposure  to  cold  while  the  process  of  desquamation  was 
going  on,  whereby  the  activity  of  the  skin  has  been  checked  or  alto- 
gether suppressed,  or  to  the  injudicious  adoption  of  a  tonic  or  stimu- 
lant plan  of  treatment,  at  a  very  early  period  of  the  patient's  convales- 
cence. The  opinion,  that  it  more  frequently  follows  a  mild  than  a 
severe  attack  of  scarlatina,  does  not  appear  to  have  any  better  founda- 
tion than  the  circumstances  that  premature  exposure  to  the  air,  and 
errors  of  diet,  are  exciting  causes  much  more  likely  to  occur  after  slight 
than  after  severe  cases.  Something,  moreover,  is  unquestionably  due 
to  the  epidemic  constitution  of  the  year,  as  Sydenham  calls  it,  since 
the  occurrence  of  the  consecutive  dropsy  is  common  after  the  scarlet 
fever  of  one  year,  comparatively  rare  after  the  same  disease  in  another 
year. 

The  treatment  of  this  affection  is  on  the  whole  that  of  inflammatory 
dropsy,  from  what  cause  soever  it  may  arise.  If  it  have  set  in  with 
severity,  the  urine  being  very  high  coloured,  extremely  scanty  and 


TREATMENT  OP  ALBUMINOUS  NEPHRITIS.  423 

loaded  with  albumen,  the  abstraction  of  blood  is  almost  indispensable, 
and  from  four  to  six  ounces  may  be  taken  from  the  arm  of  a  child  of 
five  or  six  years  old.  It  will,  I  believe,  seldom,  if  ever,  be  necessary 
to  repeat  the  general  depletion,  though  if  no  improvement  follow,  and 
especially  if  there  be  pain  or  tenderness  in  the  loins,  cupping,  or  the 
application  of  leeches  in  that  situation,  should  be  resorted  to.  At  the 
same  time,  the  child  must  be  put  on  a  low  diet :  he  must  be  kept  in  bed, 
and  must  be  placed  in  a  hot  bath  every  night,  in  order,  if  possible,  to 
excite  the  skin  to  action.  The  bowels  must  be  kept  freely  open  ;  but  I 
have  not  found  as  much  advantage  from  the  employment  of  cathartics 
as  from  the  use  of  diaphoretic  medicines.  The  tartar  emetic  is  in  these 
cases  a  very  valuable  remedy,  and  may  be  given  in  nauseating  doses 
every  three  or  four  hours  combined  with  the  solution  of  the  acetate  of 
ammonia.  If,  as  sometimes  happens,  the  child  complain  of  headache, 
or  appear  heavy  and  drowsy,  or  if  the  bowels  be  constipated,  Dover's 
powder  is  inadmissible,  though  otherwise  it  may  be  advantageously 
combined  with  the  medicine,  or  be  given  in  a  rather  larger  dose  at  bed- 
time. When  by  the  employment  of  these  means  the  skin  has  been  ex- 
cited to  action,  and  the  swelling,  if  not  actually  diminished,  has  at  least 
ceased  to  increase,  some  of  the  milder  diuretics  may  be  combined  with 
the  mixture — as  the  acetate  of  potash,  the  extract  of  taraxacum,  or  the 
spirits  of  nitrous  ether,  while  at  the  same  time  the  dose  of  the  tartar 
emetic  may  be  reduced  :  but  the  change  of  the  urine  to  a  darker  colour, 
or  the  increase  of  albumen  in  it,  should  be  regarded  as  indicating  the 
propriety  of  discontinuing  their  use,  and  of  returning  to  the  previous 
strictly  antiphlogistic  treatment. 

In  cases  where  little  or  no  fever  is  present,  and  where  the  urine, 
though  still  albuminous,  is  neither  so  scanty  nor  so  high  coloured  as  in 
the  instances  just  referred  to,  while  the  oedema  is  comparatively  slight, 
a  less  vigorous  plan  of  treatment  may  be  adopted^  The  child  should 
still  be  kept  on  low  diet,  and  confined  at  first  to  bed,  and  for  a  consi- 
derable time  afterwards  to  its  nursery,  while  the  warm  bath  should  still 
be  employed  every  night.  Bleeding,  however,  is  unnecessary ;  the  tartar 
emetic  need  not  be  administered,  but  saline  aperients,  so  given  as  to 
keep  up  a  somewhat  free  action  of  the  bowels  for  several  days,  will 
generally  suffice  to  effect  a  cure.  When,  after  the  nearly  complete 
disappearance  of  the  oedema,  and  the  return  of  the  urine  almost  or 
altogether  to  a  healthy  state,  the  child  still  continues  pale,  and  languid 
and  feeble,  the  tincture  of  the  sesquichloride  of  iron  is  the  best  tonic 
that  can  be  administered,  and  under  its  use  any  traces  of  albumen  that 
previously  existed  in  the  urine  will  be  altogether  removed.  Much  care 
is  required  in  restoring  the  child  to  its  usual  diet,  and  it  should  not  be 
allowed  to  go  abroad  without  wearing  flannel  next  its  skin  :  but  no  case 
has  come  under  my  observation  in  which  the  continuance  of  a  morbid 
state  of  the  urine  after  apparent  convalescence  from  this  affection  has 
warranted  the  apprehension  that  actual  degeneration  of  the  kidney  had 
been  produced. 

Before  leaving  this  subject,  I  must  just  observe,  that  a  slight  degree 
of  anasarca  occasionally  follows  an  attack  of  scarlet  fever  in  a  weakly 
child  as  a  mere  effect  and  indication  of  its  feebleness ;  and  also  that  an 


424  TREATMENT   OF   ALBUMINOUS   NEPHRITIS. 

affection  is  now  and  then  met  with  having  all  the  characters  of  inflam- 
matory dropsy,  except  that  the  urine  is  free  from  albumen.  This  was 
observed  in  the  dropsy  which  followed  a  recent  epidemic  of  scarlatina 
at  Berlin,1  anc^  is  likewise  mentioned  by  Dr.  Henry  Kennedy  as  having 
been  the  case  in  some  instances  of  the  secondary  dropsy  which  occurred 
during  the  Dublin  epidemic  of  the  disease.3  With  few  exceptions,  how- 
ever, it  has  been  found  that  the  affection  is  slight,  when  there  is  no 
albumen ;  its  absence  being  probably  due  to  the  congestion  of  the 
kidney  not  having  been  so  considerable  as  to  lead  to  the  rupture  of  its 
capillaries  and  the  admixture  of  blood  with  the  urine. 

Although  most  diseases  of  the  urinary  organs  are  less  common  in 
children  than  in  grown  persons,  yet  calculous  disorders  are  far  more 
frequent  in  early  life  than  in  adult  age.  It  appears,  indeed,  from  some 
statistical  data  furnished  by  Dr.  Prout,  that  out  of  1256  patients 
received  into  the  Bristol,  Leeds,  and  Norwich  hospitals,  for  the  purpose 
of  being  operated  on  for  stone,  500,  or  nearly  40  per  cent.,  were  under 
ten  years  of  age.  If  we  bear  in  mind  the  intimate  connection  that 
subsists  between  the  assimilative  and  the  excretory  functions,  it  will 
not  surprise  us  that  in  early  life,  when  the  former,  though  so  active, 
are  so  readily  disturbed,  the  latter  should  be  often  thrown  into  disorder. 

Very  slight  and  very  temporary  causes  often  suffice  to  occasion 
deposits  in  the  urine  of  children ;  and  these  deposits  almost  always 
consist  either  of  the  amorphous  lithate  of  ammonia,  or  of  the  small 
reddish  brown  crystals  of  lithic  acid.  These  deposits,  indeed,  are  not 
of  much  moment,  and  one  might  perhaps  say  that  the  younger  the 
infant  the  less  is  their  importance,  since  the  presence  of  lithic  acid  in 
considerable  quontity  in  the  kidneys  of  new-born  children  seems  to  be 
almost  a  physiological  condition.  Its  frequency  was  first  noticed  some 
years  ago,  by  Professor  Schlossberger  ;  and  his  original  statements 
have  been  confirmed  both  by  his  own  subsequent  researches,  as  well  as 
by  those  of  Professor  Martin,  of  Jena.3  Dr.  Schlossberger  on  an 
examination  of  199  children  who  died  within  thirty  days  from  birth, 
found  lithic  acid  gravel  in  the  tubuli  uriniferi  of  32  per  cent,  of  the 
number ;  in  many,  but  not  all  of  which,  some  degree  of  icterus  had 
existed.  The  frequency  of  this  condition  is  probably  connected  with 
the  peculiar  changes  in  the  processes  of  assimilation  which  take  place 
after  birth  ;  and  any  interruption  to  their  performance,  or  any  disturb- 
ance of  the  cutaneous  function,  increases,  as  in  the  case  of  infantile 
icterus,  the  probability  of  its  occurrence.  The  same  causes  exert  a 
similar  influence  both  in  infancy,  and  also  to  a  considerable  degree 
even  in  subsequent  childhood.  A  trifling  cold,  slight  gastric  disorder, 
or  the  feverishness  and  general  irritation  which  sometimes  attend  upon 
dentition,  not  infrequently  produce  these  deposits,  while  they  disappear 
as  soon  as  the  brief  constitutional  disturbance  subsides.  In  many  cases 
no  local  symptom  indicates  their  presence,  but  sometimes  the  condition 
of  the  child  is  one  of  very  considerable  suffering. 

1  Described  by  Dr.  Philip,  in  Casper's  Wochenschr.  August  29,  1840. 

2  In  his  excellent  Account  of  the  Epidemic  of  Scarlatina  in  Dublin,  from  1834  to  1842. 
12mo.     Dublin,  1842. 

3  Archiv  f.  physiol.  Heilkunde,  vol.  ix. ;  also  Schmidt's  Jahrbiicher,  Dec.  1850,  p.  333. 


THEIR   SYMPTOMS,  425 

Very  slight,  and  very  temporary  causes  indeed,  often  suffice  to  occa- 
sion abundant  deposits  in  the  urine  of  children,  and  these  deposits 
almost  always  consist  either  of  the  amorphous  lithate  of  ammonia,  or  of 
the  small  reddish  brown  crystals  of  lithic  acid.  A  trifling  cold,  or  the 
slight  feverishness  and  general  irritation  which  sometimes  attend  upon 
dentition,  not  infrequently  produce  them,  while  they  disappear  as  soon 
as  the  brief  constitutional  disturbance  subsides.  While  it  lasts,  however, 
the  condition  of  the  child  is  often  one  of  very  considerable  suffering, 
each  attempt  to  make  water  being  attended  with  much  pain,  the  patient 
crying  and  drawing  up  its  legs  towards  its  abdomen ;  while  frequently 
a  few  drops  only  of  urine  are  voided  at  each  time.  Now  and  then,  the 
suppression  of  urine  is  complete  for  twelve,,  eighteen,  or  twenty-four 
hours ;  but  this  seldom  happens,  except  in  children  previously  much  out 
of  health,  and  in  whom,  under  these  circumstances,  the  febrile  symp- 
toms and  the  constitutional  disturbance  are  very  severe,  the  bowels 
usually  constipated,  and  the  evacuations  very  unnatural  in  appearance. 
But  besides  cases  of  this  acute  kind,  which  occur  almost  exclusively  in 
infants  in  whom  the  process  of  dentition  is  not  yet  complete,  similar 
symptoms  are  often  observed  in  older  children ;  and  though  at  first  of  a 
much  less  urgent  character,  they  are  yet  of  more  serious  import,  since 
they  frequently  indicate  the  existence  of  a  calculus  in  the  bladder, 
instead  of  betokening  a  merely  temporary  excess  of  lithic  acid  deposits 
in  the  urine. 

In  many  instances,  the  formation  of  lithic  acid  in  the  kidneys  goes 
on  without  giving  rise  to  any  very  obvious  symptoms ;  and  I  have  but 
rarely  seen  a,  child  suffer  from  pain  of  that  severe  character  which  in 
the  adult  not  infrequently  accompanies  the  descent  of  a  calculus  from 
the  kidney  to  the  bladder.  Sometimes,  however,  after  frequent  attacks 
resembling  seizures  of  ordinary  colic,  a  child  begins  to  manifest  the 
symptoms  of  stone  in  the  bladder ;  and,  under  these  circumstances,  it  is 
probable  that  the  previous  attacks  of  abdominal  pain  were  due  to  the 
disordered  function  of  the  kidneys,  rather  than  to  any  primary  affection 
of  the  intestinal  canal.  The  occurrence  of  colic  in  children  of  three  or 
four  years  old,  indeed,  should  always  direct  our  most  sedulous  attention 
to  the  state  of  the  urine,  which  will  very  often  be  found  to  deviate 
widely  from  a  healthy  condition, — frequently  to  abound  in  lithic  acid 
gravel. 

The  symptoms  of  stone  in  the  bladder  are  much  the  same  at  all  ages : 
the  pain  in  voiding  urine,  and  immediately  afterwards,  the  frequent 
desire  to  pass  water,  the  occasional  abrupt  stoppage  of  the  stream  of 
urine,  and  the  irritation  about  the  penis,  owing  to  which  the  child  keeps 
its  hand  almost  constantly  on  its  genitals,  can  hardly  fail  to  awaken 
suspicion  as  to  the  nature  of  the  case.  Before  subjecting  the  child, 
however,  to  the  fright  and  pain  which  the  introduction  of  a  sound  into 
its  bladder  is  sure  to  occasion,  it  should  be  first  ascertained  that  the 
patient's  sufferings  are  not  due  to  the  prepuce  being  extremely  long  and 
its  orifice  very  narrow.  The  existence  of  that  malformation  sometimes 
prevents  the  ready  escape  of  the  urine ;  while  the  edges  of  the  foreskin 
becoming  irritated  and  sore,  any  attempt  to  make  water  is  rendered 
exceedingly  painful,  and  the  symptoms  present  a  most  deceptive  resem- 


426  TREATMENT  OF  DYSURIA. 

blance  to  those  of  stone  in  the  bladder.  The  presence  of  ascarides  in 
the  rectum  likewise  sometimes  produces  a  degree  of  irritation  about  the 
bladder,  which  is  by  no  means  unlike  that  produced  by  calculus ;  and 
against  this  possible  source  of  error  it  behooves  us  to  be  likewise  on  the 
watch. 

The  treatment  of  dysuria  in  early  life,  connected,  as  the  affection 
almost  always  is,  with  an  excess  of  lithic  acid  in  the  urine,  is  sufficiently 
simple.  Those  acute  attacks  which  come  on  during  infancy,  and  for 
the  most  part  during  the  period  of  teething,  and  which  are  attended 
with  much  fever,  with  a  constipated  or  otherwise  disordered  condition 
of  the  bowels,  and  with  severe  suffering,  obviously  call  for  antiphlogistic 
and  soothing  measures.  The  warm  bath  is  often  very  serviceable  in 
these  cases  in  relieving  the  febrile  symptoms ;  besides  which,  the  occa- 
sional immersion  of  the  child  in  hot  water,  as  high  as  the  hips,  soothes 
the  pain  which  is  so  apt  to  attend  upon  every  attempt  to  empty  the 
bladder.  The  bowels  should  be  acted  on  freely  by  castor  oil ;  and  after- 
wards, no  medicine  has  appeared  to  me  to  afford  so  much  relief  to  pain, 
or  so  effectually  to  excite  the  kidneys  to  action,  as  the  castor-oil  mix- 
ture which  I  have  already  mentioned  to  you,  in  combination  with  small 
doses  of  liquor  potassse,  laudanum,  and  nitrous  ether.  Barley-water, 
milk  and  water,  and  thin  arrow-root,  should  constitute  the  child's  nou- 
rishment during  the  severity  of  its  attack ;  and  even  when  the  symptoms 
are  on  the  decline,  much  prudence  must  still  be  exercised  in  keeping  to 
a  very  mild  and  unstimulating  diet.  It  is  generally  wise  to  continue 
the  use  of  alkalies  for  some  time  after  the  active  symptoms  have  sub- 
sided ;  and  small  doses  of  liquor  potassae,  either  alone  or  in  combination 
with  the  vinum  ipecacuanhas,  may  be  given  three  or  four  times  a  day  in 
a  little  milk.  Once  or  twice,  I  have  seen  a  sudden  suppression  of  urine, 
attended  with  great  aggravation  of  the  child's  sufferings,  follow  after  the 
existence  of  severe  dysuria  for  two  or  three  days ;  and  have  found  this 
occurrence  to  be  due  to  the  mechanical  obstruction  of  the  urethra  by  a 
small  calculus  which  had  become  impacted  in  its  canal.  The  dysuria 
which  is  produced  by  the  excessive  length  of  the  prepuce  can  be  relieved 
only  by  the  removal  of  a  portion  of  the  superfluous  foreskin ;  while, 
when  it  is  excited  by  ascarides,  an  enema  of  liquor  calcis,  with  a  dose 
or  two  of  castor  oil,  will  often  produce  an  immediate  cure  of  symptoms 
which  had  been  very  troublesome. 

The  treatment  of  calculus  in  the.  bladder  hardly  requires  special 
notice  here ;  but  you  will  bear  in  mind  that  the  calculi  which  form  in 
childhood  are  just  of  that  kind  on  which  medicinal  agents  are  best  cal- 
culated to  act ;  and  that  we  have  but  little  reason  for  dreading  those 
changes  in  the  precipitate  thrown  down  from  the  urine  which  take  place 
in  later  life.  The  deposits  that  take  place,  and  the  calculi  that  form 
in  childhood,  consist  almost  invariably  of  the  lithates,  and  hence  we 
may  employ  the  alkaline  carbonates  without  apprehension ;  and  under 
their  continued  use  I  have  seen  very  copious  sediments  completely  and 
permanently  disappear  from  the  urine.  Their  action,  however,  is  far 
too  slow  to  be  relied  on  in  any  case  where  unequivocal  signs  are  pre- 
sent of  the  existence  of  a  stone  of  considerable  dimensions ;  while,  for- 
tunately, the  anaesthetic  agents  which  we  now  possess,  by  depriving 


EXCESS   OF  LITHATES   IN   THE   URINE.  427 

the  operation  of  lithotomy  of  the  pain  that  once  attended  it,  have 
robbed  it  of  many  of  its  terrors. 

The  importance  of  lithic  acid  deposits  in  the  urine,  is,  however,  by  no 
means  dependent  on  the  temporary  suffering  associated  with  its  elimi- 
nation, in  some  instances ;  or  the  dangers  of  the  formation  of  vesical 
calculus,  in  others.  Deposits  of  lithic  acid  are  observed  in  the  urine 
of  children,  as  the  consequence  and  the  indication  of  a  state  of  general 
constitutional  disorder,  which  manifests  itself  by  dyspeptic  symptoms 
and  imperfect  nutrition,  is  often  associated  with  chronic  cutaneous  affec- 
tions, and  not  infrequently  succeeds  to  some  attack  of  rheumatism.  I 
have  already  told  you  that  rheumatism  in  the  child  runs  its  course 
frequently  with  a  much  smaller  amount  of  local  pain,  and  with  less 
swelling  of  the  joints,  than  generally  attends  it  in  the  adult.  Its  remote 
effects  also  very  seldom  shew  themselves  in  those  abiding  pains  which 
characterise  chronic  rheumatism  in  the  grown  person,  but  in  a  state  of 
general  ill  health  such  as  that  to  which  I  have  just  referred.  A  child 
is  brought  to  you  with  a  vague  history  of  failing  health  ;  of  loss  of  flesh, 
of  variable  appetite,  sluggish  bowels,  and  occasional  night  perspira- 
tions. On  further  enquiry  you  learn  that  he  is  nervous  and  excitable 
to  the  highest  degree ;  sometimes  depressed  and  sullen,  at  other  times 
so  high  spirited  as  to  be  almost  uncontrollable ;  each  of  these  fluctua- 
tions in  his  condition,  whether  for  better  or  worse,  is  found  to  be  more 
marked  at  some  seasons  of  the  year  than  at  others ;  and  often  also 
modified  by  change  of  residence,  his  health  being  manifestly  worse  in 
cold  weather,  and  in  exposed  situations,  than  in  a  sheltered  spot,  and 
during  the  summer  season.  Anxiety  lest  consumptive  disease  should 
be  impending^  often  needlessly  entertained  in  these  cases ;  but  if  you 
examine  the  urine  ycu  will  at  once  find  the  clue  that  will  help  you  to 
their  thorough  understanding.  The  urine  will  be  found  acid,  of  a  very 
high  specific  gravity,  1025°  or  upwards,  depositing  on  cooling  abundant 
red  crystals  of  lithic  acid,  and  on  the  addition  of  nitric  acid  giving  evi- 
dence, by  the  speedy  crystallization  that  takes  place,  of  the  presence  of 
an  excess  of  urea.  On  close  inquiry  you  will  probably  learn  that  some 
months  previously  the  child  had  had  an  attack  of  rheumatism,  not 
necessarily  very  severe,  and  that  since  then  his  health  had  never  been 
so  good  as  before ;  or,  if  not,  you  will  almost  certainly  find  that  rheu- 
matism is  a  disease  from  which,  in  some  or  other  of  its  numerous  forms, 
members  of  his  parent's  family  have  suffered.  It  is  to  cases  such  as 
these  that  the  term  of  the  lithic  acid  diathesis1  is  applicable. 

The  treatment  of  this  condition  does  not  require  much  notice.  A 
residence  in  a  sheltered  and  warm  situation  and  the  habitual  wearing 
of  flannel  next  the  skin,  are  two  points  of  much  importance.  A  third, 
of  at  least  equal  moment,  is  the  careful  regulation  of  the  diet,  which 
should  be  simple,  unstimulating,  and  moderate  in  quantity.  With  refe- 
rence to  medicine,  the  alkalies  and  alkaline  carbonates  may  be  given 
with  a  vegetable  bitter  if  some  decided  tonic  appears  necessary ;  but 
you  must  bear  in  mind,  and  clearly  explain  to  your  patient's  friends, 

1  It  is  almost  superfluous  to  remind  the  reader  of  Dr.  Todd's  remarks  on  this  subject 
in  his  Croonian  Lectures — On  Gout,  Rheumatism,  &c. 


428  x  INFANTILE   DIABETES. 

that  the  condition  is  not  one  to  be  overcome  in  a  short  time  by  a  few 
potent  remedies,  but  one  which  will  require  watching  and  care,  and  a 
well-considered  system  of  diet  and  regimen,  to  be  carried  on  for  months 
and  years,  and  from  which  it  is  scarcely  safe  to  depart  before  the  time 
of  puberty  has  been  passed  in  safety.  I  referred  to  it  not  because  I 
had  any  special  cautions  to  give  you  about  its  treatment,  but  to  call 
your  attention  to  a  set  of  symptoms,  the  real  signification  of  which  may 
be  readily  overlooked. 

An  unnaturally  profuse  flow  of  urine  occurs  at  all  ages  as  a  tem- 
porary symptom  in  the  course  of  many  disorders.  Its  permanent  increase, 
when  associated  with  certain  changes  in  the  composition  of  the  fluid, 
and  the  presence  of  saccharine  matters  among  its  elements,  constitutes 
diabetes.  This  disease,  although  not  common  at  any  period  of  life,  yet 
occurs  in  the  adult  sufficiently  often  for  us  to  become  familiar  with  its 
characters,  and  to  dread  it  as  one  of  the  most  formidable  results  of  dis- 
order of  the  assimilative  processes.  In  the  child,  however,  it  would 
seem  to  be  an  exceedingly  rare  affection,  for  not  only  has  no  instance 
of  it  come  under  my  notice  at  the  Children's  Infirmary,  but  Dr.  Prout, 
out  of  his  immense  experience  in  diseases  of  the  urinary  organs,  states 
that  he  has  seen  but  one  instance  of  it  in  a  child  of  five  years  old,  and 
only  twelve  in  young  persons  between  the  ages  of  eight  and  twenty 
years,  out  of  a  total  of  700  cases  of  diabetes.1  Simple  diuresis,  indeed, 
is  less  rare  than  true  saccharine  diabetes ;  and  I  have  seen  some  in- 
stances in  which,  coupled  with  serious  gastric  and  intestinal  disturbance 
there  was  so  considerable  an  increase  in  the  secretion  of  urine  as  to 
constitute  a  prominent  symptom  of  the  disease.  In  these  cases,  how- 
ever, considerable  disorder  of  the  digestive  organs  had  for  some  time 
preceded  the  excessive  flow  of  urine;  and  Dr.  Prout  states,  that  in  the 
earlier  stages  of  infantile  diuresis,  the  urine  is  loaded  with  lithates  and 
diminished  in  quantity,  though  as  the  disease  advances  the  quantity  of 
urine  becomes  considerably  increased ;  and  it  sometimes  contains  albu- 
men, or  in  rarer  cases  yields  signs  of  sugar.  So  far  as  my  observation 
goes,  indeed,  the  disturbance  of  the  functions  of  the  kidney  is  in  these 
cases  purely  secondary,  and  subsidiary  to  the  gastric  and  intestinal  dis- 
order. The  quantity  of  urine  has  either  been  speedily  diminished  under 
a  due  attention  to  diet  and  the  regulation  of  the  digestive  organs,  or 
the  symptoms  have  become  merged  by  degrees  in  those  of  phthisis, 
which  has  gradually  developed  itself.  My  experience  concerning  these 
affections  amounts,  in  short,  to  this — that  whenever  the  processes  of 
digestion  and  assimilation  are  seriously  disturbed  for  any  considerable 
time  in  early  life,  the  functions  of  the  kidney  are  very  apt  to  become 
excessive  in  degree  as  well  as  disordered  in  kind.  Further,  such  dis- 
order is  especially  likely  to  occur  just  at  that  period  when  the  simple 
but  highly  animalized  food  of  the  suckling  is  exchanged  for  the  more 
varied  diet  of  the  infant  after  weaning.  And,  lastly,  its  existence  may 
be  suspected,  whenever,  coupled  with  more  or  less  marked  indications 
of  gastro-intestinal  disorder,  there  is  a  rapidly  increasing  emaciation, 
for  which  no  adequate  cause  appears.     It  will,  however,  often  happen, 

1  On  Stomach  and  Renal  Diseases,  5th  edit.  8vo.  p.  36,  note. 


ITS   CAUSES   AND    TREATMENT.  429 

even  when  the  amount  of  urine  greatly  exceeds  the  healthy  average, 
that  the  parents  of  an  infant  take  no  notice  of  the  circumstance,  imagin- 
ing it  to  be  either  an  accidental  and  unimportant  occurrence,  or  ac- 
counting for  it  as  the  natural  result  of  the  thirst,  which  induces  the 
child  to  drink  very  abundantly.  Hence,  unless  you  make  special 
inquiries  with  reference  to  this  point,  you  may  remain  in  ignorance  of 
a  very  important  symptom. 

"When  once  you  have  become  aware  of  the  existence  of  this  affection, 
its  treatment  is  attended  by  no  particular  difficulty,  and,  if  undertaken 
sufficiently  early,  will  often  prove  successful.  The  state  of  the  bowels 
requires  most  careful  attention :  mild  alteratives  are  frequently  ser- 
viceable, but  drastic  purgatives  are  very  unsuitable.  The  Hydr.  c.  Creta;, 
in  combination  with  Dover's  powder,  is  often  very  useful  in  promoting 
a  healthy  condition  of  the  evacuations ;  while  the  Dover's  powder  alone 
is  also  beneficial  in  calming  the  child's  excessive  irritability,  as  well  as 
in  diminishing  the  amount  of  urine  secreted.  Dr.  Prout  adds  a  caution, 
however,  with  reference  to  the  use  of  opiates  in  these  cases,  as  well  as 
to  the  sudden  withdrawal  of  fluids,  since  a  suppression  of  urine  may 
follow  the  incautious  adoption  of  these  measures,  and  that  condition  is 
almost  sure  to  end  in  coma  and  death.  Change  of  air  to  a  dry  and 
temperate  situation,  especially  on  the  sea-coast,  is  of  much  importance, 
and  the  tepid  or  warm  sea-water  bath  is  often  beneficial ;  while  tonics 
of  various  kinds  are  generally  of  service.  The  different  preparations 
of  iron  appear  to  have  advantages  over  other  medicines ;  and  Dr. 
Venables,  who  was  the  first  to  call  the  attention  of  the  profession  to  this 
affection,  bestows  high  commendation  on  the  phosphate  of  iron.  Dr. 
Prout  insists^moreover,  on  the  importance  of  a  suitable  diet,  into  which 
albuminous  matters  should  enter  freely,  in  preference,  though  not  to 
the  entire  exclusion,  of  those  which  contain  gelatine.  Milk  should 
form  a  chief  element  in  the  diet ;  while  of  farinaceous  matters,  those 
are  to  be  preferred  which  have  undergone  the  fermentative  process. 
These  precautions,  too,  must  be  observed,  not  for  a  short  period  only, 
but  until  the  child  has  for  some  time  regained  its  health,  since  a  slight 
error  is  very  likely  to  be  followed  by  a  serious  relapse. 

Incontinence  of  urine  is  a  very  distressing  infirmity  from  which 
children  sometimes  suffer,  and  which,  in  many  instances,  it  is  found 
very  difficult  to  cure.  In  most  cases  this  inability  to  command  the  flow 
of  urine  exists  only  in  the  night-time,  but  sometimes  it  is  present  also 
by  day ;  and  both  forms  of  the  affection  are  met  with  in  children  of 
both  sexes  and  of  all  ages,  even  up  to  the  period  of  puberty.  The 
nocturnal  incontinence  of  urine  is  often  associated  with  the  presence  of 
an  excess  of  lithic  acid  in  the  secretion ;  and  in  such  cases  the  first  step 
towards  remedying  the  infirmity  consists  in  correcting  the  morbid  state 
of  the  fluid.  Now  and  then  it  appears  to  be  dependent  upon  the  irri^ 
tation  produced  by  ascarides  in  the  rectum,  while  in  the  majority  of 
cases,  so  long  as  the  affection  is  recent,  a  connection  may  be  clearly 
traced  between  it  and  gastro-intestinal  disorder.  If  not  remedied,  how- 
ever, all  the  other  functions  of  the  body  may  return  to  a  healthy  state, 
while  yet  the  incontinence  is  perpetuated  by  a  kind  of  habit,  which  it 
is  found  very  difficult  to  break  through. 


430  INCONTINENCE   OF   URINE. — ITS   TREATMENT. 

The  involuntary  discharge  of  urine  by  day-time  as  well  as  at  night  is 
a  still  more  troublesome  affection.  Sometimes  there  is  an  absolute 
■want  of  control  over  the  bladder ;  so  that  the  urine  is  almost  constantly 
dribbling  away;  while  in  other  cases  the  desire  to  pass  water  is  dis- 
tinctly felt  at  certain  short  intervals ;  but  the  patient  is  unable  to  resist 
this  desire  even  for  a  minute.  This  affection,  too,  is  sometimes  asso- 
ciated with  a  morbid  condition  of  the  urine ;  in  other  instances  it  seems 
to  depend  on  a  state  of  general  weakness;  while  in  some  cases  there  is 
no  apparent  cause,  either  general  or  local,  to  which  it  is  possible  to 
ascribe  it.  Cases  of  this  last  kind  are  of  all  the  most  troublesome ; 
they  are  sometimes  met  with  in  several  members  of  the  same  family, 
especially  in  girls,  though,  according  to  my  experience,  the  other  more 
curable  forms  of  incontinence  are  much  more  common  in  male  children. 

In  the  cure  of  nocturnal  incontinence  of  urine  which  may  often  be 
gained  by  attention  to  certain  precautionary  measures;  such  as  limiting 
the  quantity  of  drink  taken  at  the  last  meal,  preventing  the  child  from 
lying  on  his  back  when  in  bed  (a  position  which  seems  greatly  to  favour 
the  occurrence  of  the  accident),  and  rousing  him  from  bed  to  empty  his 
bladder  two  or  three  times  in  the  night.  If  the  urine  be  loaded  with 
lithates,  the  diet  must  be  most  carefully  regulated,  and  medicines  must 
be  given  to  restore  the  urine  to  a  healthy  state,  and  to  ensure  the  due 
performance  of  the  functions  of  the  digestive  organs.  Tonics  are  often 
extremely  useful  afterwards,  and  there  is  none  from  which  I  have  seen 
so  much  benefit  as  from  the  tincture  of  the  sesquichloride  of  iron.  At 
the  same  time,  cold  sponging  to  the  back  and  loins  is  often  decidedly 
serviceable ;  and  if  the  case  resist  these  milder  measures,  the  frequent 
application  of  a  blister  to  the  sacrum  seldom  fails  to  do  great  good.  In 
very  obstinate  cases  the  tincture  of  cantharides  is  of  service ;  and  once 
or.  twice  I  have  employed  with  advantage  large  doses  of  the  nitrate  of 
potash,  according  to  the  recommendation  of  Dr.  Young,  of  Chester ; 
but,  as  a  general  rule,  the  employment  of  these  stimulant  diuretics  is 
not  desirable. 


LECTUKE    XXXYI. 

Abdominal  Tumors.— Enlargement  of  abdomen  not  always  the  result  of  actual  disease — 
causes  to  which  it  may  be  due. — Abdominal  tumors — from  enlargement  of  the  liver, 
by  simple  hypertrophy,  by  hydatid  growths,  by  malignant  disease — from  malignant 
disease  of  the  kidney — from  enlargement  of  the  spleen — from  psoas  abscess. — Cases 
in  illustration. 

Infantile  Syphilis — its  symptoms — characters  of  the  syphilitic  cachexia — tendency  of 
the  symptoms  to  return  after  apparent  cure. — Treatment. 

Discharges  from  the  vulva  and  vagina  of  female  children — how  to  be  distinguished  from 
gonorrhoea — associated  with  debility  and  strumous  habit — difficult  of  cure. — Treatment. 

Among  the  anatomical  peculiarities  of  early  life,  none  is  more 
remarkable  than  the  great  size  of  the  abdomen,  as  contrasted  with  the 
undeveloped  state  of  the  thorax,  on  the  one  hand,  and  of  the  lower 
extremities,  on  the  other.  Though  most  striking  in  the  new-born 
infant,  it  still  continues  to  a  great  degree  during  the  whole  of  the  first 


ABDOMINAL   TUMORS.  431 

years  of  childhood;  nor  does  it  altogether  disappear  until,  with 
advancing  age,  the  pelvis  enlarges,  the  spinal  column  acquires  its 
proper  curvature,  the  limbs  gain  their  due  development,  and  the  chest 
expands  in  a  measure  commensurate  with  the  demands  made  upon  the 
thoracic  viscera  for  the  vigorous  performance  of  their  functions. 

The  anxiety  of  non-professional  persons  is  often  needlessly  excited 
by  the  large  size  of  the  abdomen  in  childhood,  while  those  even  who 
are  conversant  with  medicine  do  not  always  bear  in  mind  the  very 
different  causes  to  which  an  increase  of  its  bulk  may  be  due.  It  will, 
therefore,  I  think,  be  no  waste  of  time  to  notice  briefly  the  circum- 
stances under  which  enlargement  of  the  abdomen  may  occur  in  child- 
hood, and  to  give  you  what  little  information  I  may  be  able  to  furnish 
with  reference  to  those  diseases  which  occasion  distinct  abdominal 
tumors. 

The  abdomen  sometimes  appears  preternaturally  large,  wholly  inde- 
pendent of  any  disorder  of  the  general  health,  but  as  the  result  of  the 
child's  growth  and  development  having  gone  on  slowly,  so  that  its 
body  retains  its  infantile  proportions  but  little  altered  at  the  age  of 
two  or  three  years.  If,  as  often  happens,  this  tardy  development 
should  be  associated  with  feeble  health,  with  a  somewhat  impaired  per- 
formance of  the  digestive  functions,  and  with  a  constipated  condition 
of  the  bowels,  flatus  is  almost  sure  to  collect  in  the  intestines,  and 
the  enlargement  of  the  abdomen  is  thus  rendered  still  more  consider- 
able. With  such  a  state  of  health,  too,  some  of  the  minor  degrees  of 
rickets  are  often  associated  ;  and  even  though  no  serious  deformity 
mark  the  existence  of  the  disorder,  yet  to  its  influence  are  due  the 
undeveloped  chest  and  the  small  pelvis  ;  while  the  contracted  and  mis- 
shapen thorax,  which  is  produced  by  the  advance  of  the  disease,  makes 
the  abdominal  enlargement  appear  more  striking,  and  causes  the  child, 
according  to  MM.  Rilliet  and  Barthez'  apt  comparison,  to  resemble  the 
toy  tumblers  which  Italian  image  boys  sell  about  the  streets. 

In  cases  such  as  have  been  referred  to,  you  will  save  yourselves  and 
your  patient's  friends  much  needless  anxiety,  if  you  bear  in  mind  that 
tabes  mesenterica  is  exceedingly  rare  before  five  years  of  age,  while 
this  condition  of  general  abdominal  enlargement  is  met  with  chiefly 
between  the  commencement  and  the  end  of  the  first  dentition.  Further, 
you  will  find  that,  under  these  circumstances,  the  abdomen  is  perfectly 
soft  and  painless ;  you  will  learn  that  no  symptom  of  tubercle  has 
shown  itself;  while,  if  you  strip  the  child,  which  in  doubtful  cases  you 
ought  to  do,  you  will  probably  see  more  or  less  distinct  indications  of 
the  action  of  rickets,  either  in  deforming  the  skeleton,  or  in  disordering 
its  proportions. 

Enlargement  of  the  abdomen  is  a  much  more  frequent  attendant  on 
tubercular  peritonitis  than  on  mesenteric  disease.  The  tense,  and 
tympanitic,  and  painful,  state  of  the  abdomen,  the  sensation  of  adhesion 
between  the  abdominal  walls  and  the  subjacent  viscera,  the  loss  of  flesh, 
the  frequently  recurring  diarrhoea,  the  febrile  symptoms,  and  the  more 
or  less  well-marked  indications  of  tubercular  disease  which  attend  it, 
usually  stamp  the  nature  of  that  affection  too  clearly  for  the  attentive 
observer  to  fall  into  error. 


432  ABDOMINAL   TUMORS. 

But  besides  these  cases,  in  which  there  is  a  general  enlargement  of 
the  abdomen,  there  are  others  in  which  its  increase  of  size  is  mainly 
due  to  the  presence  of  a  distinct  and  well-defined  tumor.  A  good  many 
instances  of  this  sort  have  come  under  my  notice  at  different  times, 
though,  as  often  happens  in  Dispensary  practice,  the  number  of  those 
is  but  small  in  which  I  have  had  the  opportunity  of  watching  the  affec- 
tion to  its  close,  and  of  confirming  or  correcting  by  an  examination 
after  death  the  diagnosis  formed  during  the  life-time  of  the  patient. 

One  not  very  uncommon  cause  of  abdominal  tumor  is  enlargement  of 
the  liver,  which  sometimes  undergoes  a  very  great  increase  of  its  bulk, 
without  any  obvious  reason,  and  even  unattended  with  any  serious 
disturbance  of  the  general  health.  I  remember  a  little  girl,  about  ten 
years  old,  who  was  received  into  St.  Bartholomew's  Hospital  on  account 
of  the  very  great  enlargement  of  her  abdomen.  She  looked  very  pale, 
and  the  distension  of  the  superficial  veins  of  her  chest  and  abdomen, 
and  the  livid  congestion  of  her  face,  shewed  that  there  existed  some 
serious  obstacle  to  the  circulation.  Her  abdomen  had  been  gradually 
enlarging  for  many  months,  and  at  the  time  of  her  admission  into  the 
hospital  the  margin  of  the  liver  was  distinctly  traceable  below  the 
umbilicus ;  her  bowels  were  habitually  constipated,  but  the  evacuations 
were  natural  in  appearance,  and  the  child  was  well-nourished,  cheerful, 
and  active,  being  but  little  annoyed  by  her  great  size.  I  saw  her  again 
two  years  afterwards,  and  her  condition  was  then  quite  unaltered. 
Similar  cases,  of  what  I  believe  to  have  been  simple  hypertrophy  of 
the  liver,  have  since  come  under  my  notice.  For  the  most  part  they 
were  associated  with  very  obvious  indications  of  a  scrofulous  habit,  but 
on  one  occasion  only  was  there  any  serious  disturbance  of  the  general 
health ;  the  child  in  that  instance  suffering  from  very  severe  diarrhoea, 
which  had  succeeded  to  a  state  of  somewhat  obstinate  constipation. 

I  once  met  with  a  hydatid  tumor  of  the  liver  in  a  girl  aged  13  J 
years,  in  whom,  two  years  and  a  half  previously,  a  swelling  had  begun 
to  form  at  her  right  side,  without  any  sign  of  general  indisposition, 
though  the  subsequent  increase  of  the  growth  had  been  attended  with 
occasional  attacks  of  severe  pain.  At  the  time  of  my  seeing  her  she 
had  gone  through  a  variety  of  treatment,  which  consisted  chiefly  in 
leeching  and  the  inunction  of  iodine  ointment,  without  any  benefit ;  but 
her  general  health  was  good,  although  she  was  small  for  her  age.  On 
removing  her  dress,  the  lower  part  of  her  chest  and  the  upper  part  of 
her  abdomen  were  seen  to  be  much  enlarged  by  a  growth  the  lower 
margin  of  which  could  be  felt  a  little  above  the  umbilicus,  and  which 
seemed  larger  on  the  right  than  on  the  left  side.  At  this  time  the 
circumference  of  her  chest,  on  a  level  with  the  nipple  was  25J  inches, 
and  25  inches,. four  inches  lower  down;  but  three  years  and  a  half 
later,  and  a  short  time  before  her  death,  she  measured  32  inches  at  the 
former,  and  33  at  the  latter  point.  Even  when  I  first  saw  her,  the 
respiratory  murmur  ceased  to  be  audible  on  a  level  with  the  nipple,  and 
the  cavity  of  the  chest  became  still  more  encroached  on  with  the 
advance  of  the  disease.  Fluctuation  was  distinctly  perceptible  over 
nearly  the  whole  of  the  tumor  in  the  chest  as  well  as  in  the  abdomen, 
and  continued  so  during  the  whole  of  the  patient's  life.    It  was  in  May 


EXAMINATION   AFTER   DEATH.  433 

1840  that  the  patient  first  came  under  my  notice,  and  no  change  what- 
ever took  place  in  her  condition  until  February  1842.  At  that  time, 
after  severe  pain  in  the  tumor  had  been  experienced  for  several  days,  a 
fresh  growth  made  its  appearance,  of  about  the  size  of  a  breakfast-cup, 
to  the  left  of  the  umbilicus,  and  a  little  above  it.  In  July  following, 
the  patient  began  to  lose  flesh,  her  appetite  failed,  and  she  began  to 
suffer  frequent  attacks  of  palpitation.  At  this  time,  and  often  subse- 
quently, the  child  complained  of  pain  and  numbness,  extending  down 
the  right  arm.  Notwithstanding  the  progressive  increase  of  the  tumor, 
the  patient's  health  continued  tolerably  good  for  the  succeeding  seven- 
teen months,  though  she  grew  but  little,  and  no  signs  of  approaching 
puberty  appeared.  In  the  middle  of  December  1843,  symptoms  of 
gastric  disorder  showed  themselves:  the  child  suffered  much  from 
flatulence,  had  occasional  diarrhoea,  severe  pain  in  her  abdomen,  great 
feverishness,  and  her  mind  wandered  a  little  at  night.  The  skin  grew 
jaundiced,  and  her  water  became  very  high  coloured ;  while  the  attacks 
of  pain,  chiefly  referred  to  the  epigastrium,  sometimes  were  so  severe 
that  the  patient  fainted  from  their  intensity.  Slight  cough  came 
on,  and  for  three  weeks  before  death  she  was  unable  for  a  moment  to 
assume  the  recumbent  posture.  Her  strength  gradually  failed,  and 
she  died  on  Jan.  28,  1844,  during  an  unusually  severe  attack  of  pain. 

On  opening  the  abdomen,  from  which  a  gallon  and  a  half  of  transpa- 
rent yellow  scum  escaped,  the  enormously  large  liver  was  brought  into 
view.  It  reached  down  to  somewhat  below  the  false  ribs  on  the  left 
side,  not  quite  so  low  on  the  right,  and  extended  upwards  on  the  left, 
pushing  thexdiaphragm  before  it  to  rather  above  the  upper  margin  of 
the  second  rib\and  on  the  right  side  to  a  little  above  the  level  of  the 
third.  This  enlargement  seemed  made  up  of  the  left  lobe,  for  the  right 
lobe,  rather  dark  but  otherwise  healthy,  was  found  pushed  downward  by 
it  into  the  right  flank.  The  surface  of  the  enormously  enlarged  left 
lobe  was  of  a  pale  colour :  on  making  an  incision  into  it,  it  was  found 
to  have  formed  a  sac,  the  parietes  of  which  were  about  a  third  of  an 
inch  thick,  containing  a  gallon  of  viscid  yellow  fluid,  and  a  number  of 
hydatids  of  large  size.  The  sac  itself  appeared  to  be  formed  by  the 
parent  hydatid,  the  parietes  of  which  were  firmly  adherent  to  the  sub- 
stance of  the  liver.  At  the  anterior  edge  of  the  right  lobe  of  the  liver, 
just  to  the  right  of  the  gall-bladder,  was  a  yellowish  white  tumor  of  the 
size  of  a  walnut,  which,  on  being  cut  into,  was  seen  to  be  composed  of 
dead  and  shrivelled  hydatids  ;  they  were  folded  together,  one  within  the 
other,  like  the  coats  of  an  onion,  except  that,  in  order  to  reduce  the 
space  they  occupied  as  much  as  possible,  they  were  plicated.  The  two 
or  three  outer  layers  had  begun  to  be  the  seat  of  cretaceous  deposits. 
The  gall-bladder  contained  a  little  pale,  fluid,  bile. 

The  lungs  were  healthy,  though  much  compressed.  The  valves  of  the 
heart  were  quite  healthy,  but  the  pericardium  was  universally,  and  in 
some  parts  very  firmly,  adherent  to  its  substance ;  the  result,  doubtless, 
of  inflammation,  which  most  likely  came  on  at  the  time  when  the  child 
began  to  complain  of  palpitation  of  the  heart.  The  other  viscera  were 
quite  healthy. 

I  have  once  seen  the  liver  in  the  child  the  seat  of  malignant  disease 

28 


434  FUNGOID   DISEASE   OF   THE   LIVER — OF   THE   KIDNEYS. 

of  the  fungoid  kind,  in  the  progress  of  which  the  organ  acquired  a  very- 
large  size.  The  affection  was  attended  by  vague  indications  of  abdo- 
minal disease,  in  which  there  was  nothing  that  pointed  especially  to  any 
one  viscus,  while  the  morbid  growth,  having  originated  from  the  under 
surface  of  the  right  lobe  of  the  liver,  was  supposed,  from  the  relations 
which  it  presented,  to  be  due  to  enlargement  of  the  mesenteric  glands. 
The  patient  was  a  little  boy,  who  was  eight  months  old  when  the  first 
indications  of  disordered  health  appeared,  in  diarrhoea,  fretfulness,  and 
loss  of  flesh  and  appetite ;  and  at  the  age  of  nine  months  his  mother 
noticed  some  solid  masses  in  the  abdomen,  though  from  the  commence- 
ment of  his  illness  his  belly  had  been  hard  and  rather  tender.  The 
child  lived  to  the  age  of  one  year ;  and  for  the  last  six  weeks  of  his  life, 
during  tvhich  time  I  had  the  opportunity  of  watching  him,  he  suffered 
from  diarrhoea,  which  was  occasionally  very  profuse.  He  became  ex- 
tremely emaciated,  and  his  skin  assumed  an  exceedingly  sallow  colour  ; 
but  the  evacuations,  though  relaxed,  were  otherwise  natural.  No 
hasmorhage  took  place  from  the  intestines,  and  the  urine  was  found  to 
be  perfectly  natural  whenever  it  was  tested.  During  the  last  month  of 
his  life  he  had  a  slight  cough  and  wheezing  respiration  ;  but  death 
seemed  due  to  the  constant  diarrhoea  and  the  severe  pain  which  the  child 
suffered ;  his  exhaustion  being  doubtless  in  great  measure  the  conse- 
quence of  the  blood  which  should  have  nourished  his  body  being  diverted 
to  supply  the  enormous  mass  of  fungoid  disease  of  the  liver. 

During  the  six  weeks  that  the  child  was  under  my  observation,  his 
abdomen  increased  from  twenty-one  to  twenty-five  inches  in  circum- 
ference, and  the  tumor,  the  surface  of  which  was  uneven,  was  always 
much  larger  on  the  left  than  on  the  right  side.  It  turned  out,  however, 
on  an  examination  after  death,  that  the  left  lobe  of  the  liver  was  almost 
completely  healthy,  but  that  it  had  been  driven  up  under  the  ribs  by 
the  enlarged  right  lobe ;  which  part  of  the  organ  was  converted  into  a 
soft,  white,  brain-like  matter,  intermingled  with  which  were  portions  of 
a  firmer,  highly  vascular,  fibro-cellular  substance.  The  disease,  in 
short,  consted  of  a  mixture  of  carcinoma  medullare,  and  carcinoma 
fasciculatum.  A  few  deposits  of  medullary  cancer,  one  of  them  as  big 
as  a  walnut,  existed  also  in  the  right  lung,  but  the  other  viscera  were 
healthy. 

Malignant  disease  of  the  kidney  is  another  occasional  cause  of  abdo- 
minal tumor  in  children,  and  of  this  I  have  met  with  two  instances. 
The  first  occurred  in  a  boy,  who  died  at  the  age  of  two  years  and  ten 
months  ;  and  the  second  in  a  girl,  who  was  fourteen  months  old  at  death. 
In  the  former  case,  at  the  same  time  that  the  child  became  languid  and 
fretful  his  abdomen  was  observed  to  be  enlarging.  For  a  few  days  in 
the  early  part  of  his  illness  he  was  reported  to  have  passed  bloody 
urine  ;  but  this  symptom  did  not  recur  during  the  subsequent  progress 
of  the  disease.  In  proportion  as  his  abdomen  increased  in  size,  he  be- 
came more  and  more  emaciated :  he  had  occasional  attacks  of  diarrhoea, 
but  nevertheless  his  appetite  continued  craving  ;  and  it  was  not  till  ten 
months  after  the  first  symptom  had  been  noticed  that  the  child  died, 
exhausted.  In  the  case  of  the  girl,  the  disease  ran  a  much  more  rapid 
course,  and  death  took  place  in  ten  weeks  from  the  appearance  of  the 


TUMOR   FROM   PSOAS   ABSCESS.  435 

first  symptom.  She  was  attacked  with  feverishness,  gastric  disorder, 
and  occasional  vomiting,  which  had  not  continued  more  than  a  week 
when  her  mother  noticed  a  tumor  in  the  abdomen.  When  these  symp- 
toms came  on,  the  child  was  well  nourished,  but  she  lost  flesh  rapidly 
in  proportion  as  her  abdomen  increased  in  size ;  her  evacuations  were 
often  very  unnatural,  but  at  no  time  was  there  either  diarrhoea  or  hema- 
turia. Towards  the  end  of  her  life  she  became  very  fretful,  and  seemed 
occasionally  to  suffer  severe  pain  in  the  abdomen  ;  but  her  death  took 
place  suddenly,  and  without  any  sign  of  her  health  being  worse  than  it 
had  appeared  to  be  for  some  days  before.  In  one  case  the  left,  in  the 
other  the  right  kidney,  was  the  seat  of  the  disease  :  the  local  symptoms 
were  very  similar  in  both  instances,  and  consisted  in  the  presence  of 
a  solid  tumor  occupying  the  lumbar  region,  and  extending  from  the 
spine  across  the  abdomen  towards  the  opposite  side,  and  reaching  up- 
wards beneath  the  ribs,  and  downwards  towards,  and  in  the  first  case 
even  into,  the  pelvis.  On  examining  the  body  after  death,  the  nature 
of  the  disease  was  seen  in  both  instances  to  be  precisely  the  same,  being 
a  mixture  of  cerebriform  matter  and  of  the  peculiar  structure  of  fungus 
nematodes,  while  in  both  the  kidney  was  considerably  bigger  than  the 
head  of  an  adult. 

In  connection  with  this  subject,  I  must  warn  you  of  the  possibility  of 
mistaking  the  swelling  formed  by  a  psoas  abscess  for  that  produced  by 
enlargement  of  the  kidney.  When  psoas  abscess  occurs  in  young 
children,  its  early  stages  may  readily  be  overlooked,  partly  because  the 
patient  is  unable  to  describe  those  vague  sensations  of  uneasiness  in 
the  loins  byxwhich  it  is  attended, — partly  because  impairment  or  loss  of 
the  power  of  walking  is  so  common  a  result  of  indisposition  of  any  kind 
in  early  life  that  it  seems  scarcely  necessary  to  seek  for  any  special 
cause  to  explain  its  occurrence.  The  gradual  failure  of  the  health,  the 
loss  of  flesh  and  the  occasional  disturbance  of  the  bowels,  are  symp- 
toms that  attend  upon  various  disorders  of  the  abdominal  viscera,  and 
that  present  nothing  pathognomonic  of  any.  The  tumor,  like  that 
formed  by  enlargement  of  the  kidney,  occupies  the  lumbar  region,  pro- 
jecting forwards  into  the  abdomen  ;  while  fluctuation  in  the  abscess  is 
often  so  obscure,  as  to  be  scarcely,  if  at  all,  perceptible.  The  tumor 
of  psoas  abscess,  however,  reaches  less  high  up  in  the  abdomen  than 
that  formed  by  enlargement  of  the  kidney  :  its  contour  is  usually  more 
circular,  less  oval,  and  the  tenderness  over  it  is  in  general  greater, 
than  in  cases  of  malignant  disease  of  the  kidney.  As  the  affection 
advances,  and  the  matter  gravitates  into  the  thigh,  or  points  in  the 
lumbar  region,  its  nature  becomes  clearly  manifest;  but  though,  as  far 
as  the  final  issue  of  the  case  is  concerned,  an  error  of  diagnosis  is  of 
but  little  import,  it  is  yet  very  desirable  for  your  own  reputation  that 
you  should  not,  at  any  period,  have  fallen  into  a  mistake  as  to  its 
nature. 

In  this  country,  and  especially  in  the  neighbourhood  of  London, 
where  the  severer  forms  of  intermittent  fever  seldom  occur,  we  do 
not  often  meet  with  instances  of  that  enlargement  of  the  spleen  which 
is  common  enough  even  among  children  in  malarious  districts,  and 
usually,  though  not  invariably,  succeeds  to  previous  attack  of  ague. 


436  ENLARGEMENT   OF   THE   SPLEEN. 

The  only  instance  of  it  which  I  have  had  the  opportunity  of  observing 
was  presented  by  a  little  girl,  six  years  and  a  half  old,  who  had  lived 
at  Fernando  Po  from  the  age  of  two  years  and  a  half,  having  had 
dysentery  at  three  years  old,  and  frequent  attacks  of  fever  subse- 
quently. The  enlargement  of  her  spleen  had  first  become  apparent  at 
five  years  of  age ;  and  when  I  first  saw  her,  a  few  weeks  after  her 
return  from  Africa,  it  had  attained  so  considerable  a  size  that  her 
abdomen  measured  twenty-one  inches  and  a  half  in  circumference. 
The  spleen  in  this  case  reached  from  under  the  ribs  quite  down  into 
the  pelvis,  and  forwards  as  far  as  the  mesial  line  of  the  abdomen. 
Independently  of  the  patient's  history,  which  in  a  case  of  this  kind 
would  be  of  itself  sufficient  to  prevent  an  erroneous  diagnosis,  the 
relations  of  the  swelling  were  characteristic ;  for,  although  situated  at 
the  side  of  the  abdomen,  it  did  not  extend  backwards  into  the  lumbar 
region  so  as  to  fill  it  up  completely,  as  an  enlarged  kidney  would  do, 
but  a  considerable  interval  existed  between  the  posterior  margin  of 
the  tumor  and  the  vertebral  column. 

Though,  in  the  cases  which  I  have  just  related  to  you,  the  enlarge- 
ment of  the  abdomen  was  in  general  due  to  malignant  disease,  yet  I 
would  not  have  you  too  ready  to  pronounce  an  unfavourable  prognosis 
.concerning  cases  in  which  you  find  some  increase  in  the  size  of  the 
abdomen,  and  that  increase  apparently  associated  with  the  presence  of 
a  definite  tumor.  A  decided  opinion  can  seldom  be  formed  after  seeing 
such  cases  only  once ;  for,  in  addition  to  the  usual  sources  of  fallacy, 
there  are  those  special  difficulties  which  arise  from  the  child's  unwil- 
lingness to  submit  to  any  protracted  examination,  and  which  compel 
us  to  acquire  our  knowledge  by  instalments.  Moreover,  the  rate  of 
increase  of  the  tumor,  the  changes  in  its  contour,  and  in  its  relations 
to  the  abdominal  viscera,  often  require  to  be  carefully  noticed,  before 
you  can  venture  to  pronounce  upon  it  with  any  certainty.  I  have 
indeed  known  some  instances,  where  the  complete  disappearance  of 
manifest  abdominal  tumor,  and  the  eventual  recovery  of  perfect  health, 
have  belied  the  unfavourable  opinion  which  I  had  expressed.  I  wish 
that  I  could  give  you  some  criterion  for  distinguishing  the  hopeful 
cases  from  those  which  are  hopeless  ;  but  even  this  caution  as  to  the 
possibility  of  error  may  not  be  without  its  use. 

According  to  the  plan  which  we  proposed  to  follow  in  this  course  of 
lectures,  it  remains  for  us  now  to  study,  in  conclusion,  the  febrile  dis- 
eases of  infancy  and  childhood.  There  is  one  affection,  however,  too 
important  to  be  passed  over  in  silence,  although  it  cannot  be  assigned 
to  any  of  those  classes  into  which,  for  convenience  sake,  we  distributed 
the  diseases  of  early  life.  I  propose,  therefore,  to  devote  the  remaining 
half  hour  of  to-day  to  the  study  of  infantile  syphilis,  and  to  defer  till 
to-morrow  the  consideration  of  the  fevers  and  exanthemata. 

Syphilis,  as  it  occurs  in  the  infant,  presents  many  important  dif- 
ferences from  the  characters  which  it  assumes  in  the  adult ;  nor  is  there 
in  this  any  thing  to  excite  our  surprise,  if  we  bear  in  mind  the  very 
different  circumstances  under  which,  in  the  two  cases,  the  poison  infects 
the  organism.  In  the  adult,  the  manifestations  of  the  disease  are 
almost  always  the  result  of  the  direct  inoculation  of  the  system  with 


INFANTILE    SYPHILIS.  437 

the  venereal  virus.  In  the  child,  infection  by  that  mode  seldom  occurs. 
The  supposition,  once  generally  entertained,  that  an  infant  becomes 
affected  with  syphilis  in  consequence  of  its  body  being  brought,  during 
the  time  of  its  birth,  into  contact  with  venereal  sores  upon  the  mother's 
genitals,  is  now  deservedly  regarded  as  altogether  erroneous.  The 
infection  of  a  child  by  sucking  the  breast  of  a  syphilitic  nurse,  is,  to  say 
the  least,  a  very  unusual  occurrence ;  and  the  weight  of  evidence  is 
dacidedly  against  its  ever  taking  place.  In  by  far  the  greater  number 
of  cases  the  infant  has,  without  doubt,  contracted  the  disease  in  the 
womb,  although  its  indications  comparatively  seldom  shew  themselves 
until  at  least  fourteen  days  after  birth.  In  many  of  these  cases  the 
mother  has,  during  her  pregnancy,  been  the  subject  of  primary  syphilis, 
or  if  not,  has  presented  well-marked  secondary  symptoms;  and  under 
either  of  these  conditions  we  can  understand  that  her  infected  blood 
may  deteriorate  that  of  her  infant,  and  give  rise  to  consequences  more 
or  less  analogous  to  those  from  which  she  has  recently  suffered  herself. 
Cases,  however,  are  now  and  then  met  with,  in  which  the  venereal  taint 
appears  to  have  been  derived  entirely  from  the  father ;  the  mother,  as 
far  as  can  be  ascertained,  not  having  suffered  at  any  time  either  from 
primary  or  secondary  symptoms,  although  she  has  given  birth  to  an 
infant  affected  with  all  the  characteristic  marks  of  syphilitic  disease. 

Through  whichever  of  these  media  the  infant  becomes  infected  with 
syphilis,  symptoms  of  the  same  kind  appear,  though  there  is  no  inva- 
riable order  in  which  they  shew  themselves ;  and  coryza  is  its  earliest 
indication  in  one  case,  a  cutaneous  eruption  in  a  second,  ulceration 
about  the  corners  of  the  mouth  in  a  third.  When  we  consider  the  fre- 
quency with  wjiich  abortion  or  premature  labour  appears  to  be  due  to 
the  influence  of  the  syphilitic  poison,  it  might  naturally  be  expected 
that  cases  should  be  by  no  means  unusual  in  which  infants  at  the  moment 
of  their  birth  should  present  evidences  of  the  venereal  taint.  This, 
however,  is  very  seldom  the  case, — so  seldom,  indeed,  that  I  do  not 
remember  to  have  met  with  an  instance  of  it;  neither  has  any  case 
come  under  the  notice  of  M.  Trousseau,  of  Paris,1  whose  appointment  at 
the  Hopital  Necker  in  that  city  gave  him  most  ample  opportunities  for 
observing  the  diseases  of  early  infancy.  Children,  although  infected 
with  syphilis,  and  in  whom  the  signs  of  the  disease  speedily  shew  them- 
selves, are  yet  generally  well  nourished,  and  apparently  in  good  health, 
at  the  time  of  birth.  This,  too,  is  observed  to  be  the  case  even  where 
the  mother  has  suffered  severely  from  secondary  symptoms, — has 
already  aborted  frequently,  or  has  given  birth  prematurely  to  dead 
children  whose  cuticle  was  peeling  off, — a  condition  generally  regarded, 
though  far  from  being  satisfactorily  proved,  to  be  an  effect  of  the  venereal 
poison.  When  she  at  length  produces  a  living  child,  there  is  nothing  for 
the  first  two  or  three  weeks  after  its  birth  to  distinguish  it  from  the 
offspring  of  the  most  healthy  parents.  After  the  lapse  of  that  time  the 
first  symptom  of  disease  shows  itself;  and  most  commonly  this  is 
nothing  more  than  the  occurrence  of  a  degree  of  snuffling  with  the 

1  See  his  very  valuable  memoir  on  Infantile  Syphilis,  in  the  Archives  Gen.  de  M6decine 
for  October,  1847. 


438  SYMPTOMS   OP   INFANTILE   SYPHILIS. 

child's  breathing,  and  slight  difficulty  in  sucking, — the  signs,  in  short, 
of  ordinary  coryza.  Now  and  then,  as  I  stated  some  days  ago,1  no 
other  indication  of  syphilis  appears ;  but  nevertheless  the  coryza  does 
not  yield  until  after  the  child  has  been  brought  under  the  influence  of 
mercurial  remedies, — a  fact  which  would  seem  to  shew  that,  although 
unaccompanied  with  other  signs  of  venereal  taint,  the  snuffles  of  young 
infants  are  sometimes  produced  by  that  cause.  In  the  majority  of 
instances,  however,  the  coryza  does  not  continue  long  without  charac- 
teristic signs  of  disease  appearing  about  the  nostrils  themselves,  and 
without  syphilitic  eruptions  breaking  out  upon  the  surface  of  the  body. 
The  mucous  membrane  of  the  nostrils  secretes  a  yellow  ichorous  matter, 
sometimes  slightly  streaked  with  blood,  which  drying,  obstructs  the 
opening  of  the  nostrils,  and  renders  breathing  and  sucking  very  dis- 
tressing to  the  child.  The  voice,  too,  before  long  becomes  affected,  and 
assumes  a  peculiar  hoarse  tone,  which  has  been  not  inaptly  compared 
to  the  sound  of  a  child's  penny  trumpet,  and  which,  when  you  once 
have  heard,  you  will  at  once  recognize  as  almost  pathognomonic  of 
syphilis.  This  change  of  voice  depends  no  doubt  on  the  affection  of  the 
throat,  which  you  will  often  see,  in  common  with  the  interior  of  the 
mouth,  to  be  red  and  shining,  and  to  present  many  superficial  ulcera- 
tions. The  skin  of  the  upper  lip,  over  which  the  discharge  from  the 
nostrils  runs,  often  becomes  exoriated,  or  if  not,  it  assumes  a  peculiar, 
yellowish  brown,  colour,  like  the  hue  of  a  faded  leaf.  Should  the  dis- 
ease be  unchecked,  large  patches  of  the  skin  upon  the  face  and  forehead 
put  on  this  appearance,  which  seems  due  to  a  kind  of  staining  of  the 
part,  and  is  unaccompanied  with  any  alteration  of  its  texture.  Both 
lips  before  long  become  affected :  a  number  of  minute  perpendicular 
fissures  take  place  in  them,  which  bleed  whenever  the  infant  sucks ;  and 
small  ulcerations  appear  at  either  angle  of  the  mouth.  It  generally 
happens,  however,  before  these  effects  of  the  disease  have  become  very 
obvious  about  the  mouth,  that  the  skin  in  various  parts  presents  ap- 
pearances equally  characteristic.  Though  not  limited  to  any  situation, 
the  eruption  of  syphilis  usually  makes  its  appearance  about  the  buttocks 
and  nates,  in  the  form  of  small,  circular,  shining  spots  of  a  coppery  red 
colour,  having  a  slightly  shining  surface,  and  disposed  to  become  some- 
what rough  at  their  centre  from  the  desquamation  of  the  epidermis  in 
that  situation.  The  spots  in  the  neighbourhood  of  the  anus  often 
degenerate  into  small,  soft,  spongy  ulcerations,  with  a  slightly  elevated 
base ;  the  margins  of  the  anus  become  fissured;  and  the  skin  about  the 
scrotum  and  along  the  inside  of  the  thighs  grows  red,  sore,  cracked, 
shining,  and  denuded  of  its  epidermis.  The  eyes  grow  weak,  the  mar- 
gins of  the  eye-lids  sore,  and  a  scanty,  adhesive,  puriform  secretion  is 
poured  out  from  the  Meibomian  glands,  attended  with  but  little  redness 
of  the  conjunctiva.  Sometimes,  too,  the  hair  of  the  head  drops  off,  as 
small,  red,  sometimes  slightly  elevated  spots,  extend  over  the  scalp. 

The  child  is  generally  by  this  time  reduced  to  the  last  stage  of  weak- 
ness and  attenuation,  but  even  when  the  disease  proves  fatal,  it  does 
not,  as  in  the  adult,  affect  the  bones.     I  have  chanced,  indeed,  to  see  one 

i  In  Lecture  XV.  p.  169. 


PROGRESS    OF    THE   DISEASE.  4S9 

instance  of  destruction  of  the  bony  palate  from  this  cause  in  an  infant 
of  a  few  months  old,  but  so  rare  is  the  occurrence  that  the  late  Mr. 
Colles  of  Dublin,1  notwithstanding  his  immense  experience,  states  that 
he  had  never  observed  it.  Should  life  be  prolonged  after  the  disease 
has  reached  an  advanced  stage,  its  further  manifestations  consist  in  the 
formation  of  small  pustules  about  the  mouth,  especially  upon  the  lower 
lip  and  chin,  which  destroy  the  cutis,  and  leave  the  surface  after  they 
have  healed  much  scarred  by  their  cicatrices.  The  epidermis,  too,  in 
some  bad  cases  peels  off  the  hands  and  feet :  it  generally  becomes  thick- 
ened to  a  kind  of  crust,  like  that  which  forms  on  the  hands  in  psoriasis 
palmaria,  and  then,  cracking,  falls  off  in  patches,  leaving  the  skin 
fissured  and  sometimes  deeply  ulcerated  at  the  bend  of  the  wrist,  or  at 
the  flexures  of  the  fingers  and  toes.  The  new  and  delicate  epidermis 
in  its  turn  undergoes  a  similar  thickening,  and  becomes  detached  in 
the  same  manner,  or  else  it  continues  white  and  thin,  but  shrivelled, 
and  looking  like  the  sodden  and  wrinkled  skin  of  a  washerwoman's 
hand,  and  peeling  off  in  little  fragments,  leaves  the  cutis,  especially  at 
the  tips  of  the  fingers  and  toes,  red,  and  bleeding  slightly,  even  on  the 
gentlest  touch. 

Although  such  are  the  effects  that  may  flow  from  infantile  syphilis 
when  it  runs  its  course  unchecked,  it  yet  happens  but  rarely  that  we 
meet  in  any  case  with  all  the  symptoms  that  have  just  been  described. 
Most  serious  constitutional  disturbance  is  associated  with  the  local 
mischief,  and  the  child  often  falls  a  victim  to  the  former,  when  the  out- 
ward signs  of  syphilitic  disease  are  yet  comparatively  slight.  It  wastes 
rapidly,  it  suffers  from  sickness,  or  its  bowels  become  much  purged ;  it 
is  constantly  fretful  and  uneasy  ;  the  advance  of  ossification  is  arrested ; 
the  head  feels  soft,  and  the  anterior  fontanelle  is  large  ; — circumstances 
which  sometimes  lead  to  the  suspicion  that  chronic  hydrocephalus  has 
come  on,  though,  if  the  poison  of  syphilis  should  be  eradicated  from  the 
system,  the  completeness  of  the  patient's  recovery  shows  that  no  serious 
cerebral  disease  had  existed.  In  children  affected  by  this  syphilitic 
cachexia,  not  only  are  the  loss  of  flesh,  and  that  withered  aspect  which 
gives  to  infancy  the  appearance  of  old  age,  very  remarkable,  but  also 
the  bloodless  state  of  the  conjunctiva,  and  the  yellow  waxen  hue  of  t^he 
skin,  like  that  of  a  person  who  has  been  reduced  to  the  most  extreme 
degree  of  anaemia.  Even  in  children  who  have  survived  their  earliest 
infancy,  and  in  whom  the  disease,  though  not  completely  eradicated, 
has  yet  been  kept  in  check,  this  colour  of -the  skin  continues,  and  seems, 
indeed,  to  be  an  almost  pathognomonic  sign  of  the  affection  from  which 
they  are  suffering. 

When  imperfectly  cured,  other  indications  of  the  disease  remain 
besides  the  impairment  of  the  general  health,  the  loss  of  flesh,  and  the 
peculiar  colour  of  the  skin,  or  at  least,  if  not  constantly  present,  they 
show  themselves  from  time  to  time,  reappearing  at  uncertain  intervals, 
without  there  being  any  fresh  cause  for  their  manifestation.  Such 
symptoms  are  the  return  of  the  small  copper-coloured  spots,  which, 
however,  seldom  reappear  in  considerable  numbers  ;  the  general  loss  of 

1  Practical  Observations  on  the  Venereal  Disease,  8vo.  p.  271.     London,  1837. 


440  CHARACTERS   OF   THE   SYPHILITIC   CACHEXIA. 

hair ;  the  existence  of  a  slight  degree  of  coryza  ;  the  appearance  of  one 
or  two  soft  tubercular  elevations,  with  ulcerated  summits,  about  the 
organs  of  generation,  or  the  outbreak  of  a  very  severe  and  unmanage- 
able intertrigo.  In  other  instances,  there  are  few  local  signs  of  the 
disease  beyond  the  occurrence  of  small  ulcerations  at  each  angle  of  the 
mouth,  or  the  development  of  large  soft  condylomata  at  the  verge  of 
the  anus,  or  in  a  few  instances  the  formation  of  exceedingly  trouble- 
some ulcerations,  having  a  slightly  elevated  base,  between  the  fingers 
and  toes,  which  last  appearances  seem  to  belong  to  the  tertiary  rather 
than  to  the  secondary  consequences  of  syphilitic  disease. 

The  duration  of  the  disease,  and  the  mode  in  which  it  proves  fatal, 
vary  in  different  cases ;  for  while  death  sometimes  takes  place  speedily 
under  the  first  outbreak  of  its  symptoms,  life  is  in  other  instances  pro- 
longed for  several  months.  In  cases  of  this  kind  the  more  marked 
signs  of  the  disease  recede  for  a  time  either  spontaneously  or  under 
medical  treatment,  but  the  evidences  of  the  syphilitic  cachexia  continue, 
the  child  never  regains  its  health,  glandular  enlargements  take  place, 
and  it  either  dies  phthisical,  or  else  drags  out  a  miserable  existence  until 
some  intercurrent  disease,  as  pneumonia  or  diarrhoea,  supervenes  and 
destroys  it. 

But  though  the  consequences  of  infantile  syphilis  are  so  serious,  if  it 
be  either  let  alone  or  inefficiently  treated,  a  fatal  result  seldom  takes 
place  if  remedies  be  employed  before  the  syphilitic  cachexia  has  become 
fully  established,  and  if  treatment,  when  once  begun,  be  perseveringly 
continued  for  some  time  after  the  complete  disappearance  of  every 
symptom.  This,  indeed,  sometimes  implies  the  continuance  of  treat- 
ment for  two  or  even  three  months ;  for  so  long  as  any  symptom  remains, 
be  it  only  a  slight  spot  of  eruption,  or  a  small  condyloma  about  the  anus, 
the  suspension  of  remedies  will  be  certainly  followed  by  the  reappear- 
ance of  the  whole  train  of  symptoms.  Even  after  the  apparent  cure  of 
the  affection,  it  is  not  wise  hastily  to  omit  all  medicines,  since,  just  as 
in  the  adult,  the  symptoms  have  a  great  tendency  to  recur. 

Mercury  in  some  form  or  other  appears  to  be  indispensable  to  the 
cure  of  this  affection.  It  has  been  recommended  by  some  writers  not 
to  administer  it  directly  to  the  child,  but  to  content  ourselves  with 
bringing  the  mother's  system  gently  under  the  mercurial  influence,  and 
to  cure  the  infant  through  her  medium.  In  some  slight  cases  this  may 
suffice,  and  in  almost  all,  the  cure  of  the  infant  is  materially  expedited 
by  the  administration  of  the  remedy  to  its  mother ;  but  I  think  that,  as 
a  general  rule,  it  is  expedient  to  give  mercury  likewise  to  the  child. 
For  internal  administration  I  prefer  the  hydrargyrum  cum  creta,  to  any 
other  form  of  the  remedy,  and  give  it  in  doses  of  a  grain  twice  a  day  to 
a  child  of  six  weeks  old,  combining  it  with  two  or  three  grains  of  chalk 
if  the  bowels  be  disturbed  at  the  time  of  commencing  the  treatment,  or 
if  they  become  so  during  its  continuance.  I  have  never  found  it 
seriously  disagree,  though  sometimes  it  causes  sickness,  in  which  case 
small  doses  of  calomel,  or  of  the  solution  of  corrosive  sublimate,  may  be 
substituted  for  it.  In  some  cases,  whatever  be  the  form  of  mercurial 
employed,  its  protracted  use  occasions  such  great  irritability  of  the  sto- 
mach, that  we  are  compelled  to  discontinue  the  remedy.     Usually,  the 


TREATMENT   OF   INFANTILE    SYPHILIS.  441 

child  becomes  able  to  take  it  again,  after  a  pause  of  two  or  three  days ; 
but  if  this  should  not  be  the  case,  we  must  leave  it  oif,  and  content  our- 
selves with  ordering  a  scruple  of  mercurial  ointment  to  be  rubbed  into 
the  thighs  or  the  axilla  twice  a  day ;  or  with  letting  the  child  wear  the 
mercurial  belt.  This  simple  contrivance,  which  consists  in  nothing  else 
than  swathing  a  piece  of  flannel,  the  inner  surface  of  which  is  smeared 
daily  with  the  Unguentum  Hydrargyri,  around  the  abdomen  of  the 
infant,  is  spoken  of  by  those  who  have  employed  it  most  as  being  an 
exceedingly  efficacious  method  of  bringing  the  system  under  the  influence 
of  mercury,  and  as  free  from  all  the  risks  of  disordering  the  child's 
health  which  attend  upon  the  internal  administration  of  that  remedy. 
In  Dispensary  practice  I  confess  that  I  have  scarcely  tried  its  merits  ; 
for  I  found  that  while  I  could  give  powders  without  suspicion,  the  mer- 
curial ointment  was  known;  and  inconvenience  arose  from  the  remedy 
betraying  the  nature  of  the  disease.  This  objection  might  probably 
have  been  got  rid  of  by  colouring  the  ointment  with  cinnabar ;  but  my 
experience  of  the  grey  powder  was  on  the  whole  so  satisfactory,  that  I 
felt  the  less  anxious  to  try  a  new  plan  of  treatment. 

As  a  local  application  to  the  sores,  the  black  wash  usually  agrees 
better  than  anything  else,  but  the  large  soft  condylomata,  which  form 
about  the  anus,  often  require  to  be  touched  with  the  solid  nitrate  of 
silver.  It  very  often  happens  that  as  the  syphilitic  symptoms  disappear, 
the  health  of  the  child  becomes  perfectly  restored  under  the  use  of  no 
other  remedy  than  mercury.  If  this  be  not  the  case,  however,  some 
tonic  medicine  or  other  must  be  given.  If  the  bowels  be  disordered, 
the  liquor  cinchonse,  or  the  extract  of  sarsaparilla,  will  be  found  very 
useful.  If  there  be  no  gastric  or  intestinal  irritation,  minute  doses  of 
iodide  of  potass  may  be  given  in  combination  with  the  extract  of  sarsa- 
parilla ;  but  if  the  syphilitic  cachexia  be  wTell  marked,  and  the  child  have 
suffered  long  from  the  disease,  or  have  had  frequent  returns  of  its  symp- 
toms, no  remedy  has  appeared  to  be  so  serviceable  as  the  iodide  of  iron, 
which  may  be  given  in  the  form  of  syrup,  and  is  in  most  cases  taken  by 
the  child  very  readily,  while  it  is  seldom  found  to  disagree. 

I  may  here  conclude  my  remarks  about  an  affection  which,  perhaps, 
in  strict  propriety,  scarcely  comes  within  my  province;  but  before 
closing  to-day's  lecture  I  should  wish  to  say  a  few  words  about  those 
muco -purulent  discharges  from  the  vagina  and  vulva,  in  young  girls, 
which  were  once  erroneously  supposed  to  be  due  to  some  impure  cause ; 
an  opinion  which,  though  now  justly  abandoned  by  the  profession,  still 
retains  its  hold  among  the  vulgar. 

Discharges  of  pus,  or  of  mucus  mingled  with  it,  take  place  in  female 
children  of  all  ages,  from  the  time  when  dentition  commences  down  to 
the  period  of  puberty,  but  are  most  frequent  between  the  ages  of  two 
and  seven  years.  They  are  almost  always  essentially  chronic  in  their 
character,  being  associated  in  general  writh  very  little  swelling  of  the 
sexual  organs,  and  with  little  or  no  pain  ;  but  proving  extremely  annoy- 
ing from  their  disposition  to  continue  for  a  long  time,  from  their  obsti- 
nate resistance  to  remedies,  and  their  great  tendency  to  recur  under 
very  slight  exciting  causes.  Even  when  the  discharge  is  very  profuse, 
there  is  no  great  redness  of  the  parts  from  which  it  is  poured  out ;  while 


442  TREATMENT   OF   INFANTILE   SYPHILIS.  I 

it  will  be  seen  to  be  furnished  almost  entirely  by  the  inner  surface  of 
the  labia,  by  the  nymphee  and  the  vulva  generally,  but  to  come  scarcely 
at  all  from  the  canal  of  the  vagina.  The  slight  degree  of  swelling  of 
the  parts ;  the  source  of  the  discharge  almost  exclusively  from  the  parts 
anterior  to  the  hymen ;  and  the  absence  of  dysuria,  or  the  very  slight 
degree  in  which  it  has  attended  the  onset  of  the  affection,  coupled  with 
the  integrity  of  the  hymen,  and  the  absence  of  all  appearances  of 
injury,  are  sufficient  to  distinguish  this  affection  from  gonorrhoea. 
Sometimes,  indeed,  when  this  discharge  has  come  on  during  teething, 
it  has  been  preceded  by  considerable  dysuria ;  but  older  children  rarely 
suffer  more  than  a  degree  of  itching  and  smarting  of  the  parts,  which  is 
troublesome  from  its  persistence  rather  than  from  its  severity.  When 
it  occurs  during  dentition,  the  discharge  is  not  in  general  abundant,  and 
ceases  so  soon  as  the  tooth  has  cut  through  the  gum,  though  probably 
returning  with  a  renewal  of  the  irritation.  Sometimes  it  occurs  in 
children  who  are  much  troubled  by  ascarides,  when  it  is  kept  up  in  many 
instances  not  merely  by  the  irritation  excited  by  their  presence  in  the 
rectum,  but  in  a  measure  also  by  their  creeping  about  the  vulva.  In 
some  instances  it  takes  place  as  a  sequela  of  the  eruptive  fevers,  espe- 
cially of  scarlatina;  and  though  I  have  never  met  with  it  under  these 
circumstances,  except  as  a  chronic  ailment,  accompanied  by  great  gene- 
ral debility,  cases  have  been  related,1  in  which  it  came  on  with  acute 
symptoms  on  the  decline  of  the  eruption.  Generally,  however,  it 
neither  succeeds  to  any  previous  fever,  nor  is  dependant  on  any  local 
cause,  but  occurs  in  strumous  children  in  connection  with  general 
impairment  of  health,  or  following  some  considerable  fatigue.  Where 
no  special  cause  can  be  assigned  for  its  occurrence,  its  appearance  is 
yet,  in  general,  preceded  for  a  day  or  two  by  some  slight  increase  of 
indisposition;  such  as  an  attack  of  feverishness,  or  catarrh,  or  diarrhoea. 
Be  the  cause  what  it  may,  our  great  difficulty  in  almost  every 
instance  is  to  effect  a  permanent  cure,  so  that  the  suspension  of  our 
remedies  may  not  be  followed  by  a  return  of  the  discharge.  When  it 
is  connected  with  teething,  or  with  the  presence  of  worms,  the  indica- 
tions are  plain  enough,  and  cure  is  in  general  comparatively  easy. 
Simple  but  abundant  ablution  with  tepid  water,  repeated  every  hour  or 
two  on  the  first  appearance  of  the  discharge,  will,  in  conjunction  with 
appropriate  general  treatment,  not  infrequently  suffice  for  its  complete 
arrest.  If  the  discharge,  however,  continue  for  more  than  one  or  two 
days,  astringents  must  be  had  recourse  to,  such  as  the  Liquor  Plumbi 
Dilutus,  or  lotions  of  sulphate  of  zinc,  or  of  alum,  each  of  which  may 
be  employed  for  a  few  days,  and  then  changed  for  another.  At  the 
same  time  frequent  cold  sponging  of  the  nates  and  vulva  should  be 
employed ;  and  it  must  be  impressed  on  the  child's  attendants  that  no 
lotion  whatever  can  supply  the  place  of  frequent  ablution.  Now  and 
then,  when  at  the  onset  of  the  discharge  there  has  been  more  dysuria 
than  common,  I  have  given  small  doses  of  copaiba  and  liquor  potassae  ; 
and  have  obtained  from  their  administration  just  the  same  kind  of 
relief  as  those  remedies  afford  in  acute  vaginitis  in  the  adult.     Such 

1  By  Dr.  Cormack,  in  the  London  Journal  of  Medicine,  Sept.  1850. 


'  FEVERS.  443 

cases,  however,  are  quite  exceptional ;  and  usually,  tonics,  and  expe- 
cially  preparations  of  iron,  are  the  only  internal  remedies  which  are 
required,  while  it  is  in  general  necessary  to  begin  their  administration 
early.  These  medicines,  especially  if  associated  with  change  to  the 
sea-side,  and  sea-bathing,  usually  suffice,  even  in  the  most  obstinate 
cases,  to  effect  a  cure.  It  is,  however,  in  general  a  wise  precaution  to 
continue  the  employment  of  frequent  ablution,  and,  in  addition,  to 
sponge  the  parts  twice  a  day  with  alum  lotion,  even  for  weeks  after 
the  discharge  has  completely  ceased;  while  once  I  found  the  employ- 
ment of  a  lotion  of  a  scruple  of  nitrate  of  silver  to  an  ounce  of 
water  necessary  to  arrest  a  discharge  which  had  bid  defiance  to  all 
other  remedies. 


LEC  TUEE    XXXVII  . 

Fevers — chiefly  belong  to  the  class  of  the  Exanthemata.     Mistakes  with  reference  to 

simple  fever  in  childhood— its  identity  with  fever  in  the  adult. 
Simple  or  remittent  fever  occurs  in  two  degrees — symptoms  of  its  milder  form — of  its 

severer  form— signs  of  convalescence — modes  of  death. — Diagnosis. — Treatment. 

We  come  now  to  the  last  part  of  this  course  of  lectures  ;  namely, 
to  the  study  of  the  febrile  diseases  incidental  to  infancy  and  childhood. 
They  belong,  for  the  most  part,  to  the  class  of  the  Exanthemata, — 
diseases  characterized,  as  you  know,  by  very  well-marked  symptoms, 
by  a  very  definite  course,  and  by  usually  occurring  only  once  in  a 
person's  life.  These  peculiarities  have  always  obtained  from  them  the 
notice  of  practitioners  of  medicine,  and  few  of  the  affections  of  early 
life  have  been  watched  so  closely,  or  described  with  so  much  accuracy, 
as  small  pox,  measles,  and  scarlatina.  Hence  it  will  be  unnecessary  to 
occupy  so  much  of  your  time  with  their  investigation  as  we  have 
devoted  to  the  study  of  other  diseases  which,  though  not  so  important, 
have  yet  been  less  carefully  or  less  completely  described. 

While  the  well-marked  and  unvarying  features  of  the  eruptive  fevers, 
however,  have  forced  those  diseases  on  the  attention  of  all  observers, 
the  more  fluctuating  characters  of  simple  continued  fever  have  been  so 
masked  by  the  differences  between  youth  and  age,  that  the  affection  as 
it  occurs  in  early  life  was  long  almost  entirely  overlooked,  and  its  nature 
was,  in  many  respects,  still  longer  misapprehended.  Many,  indeed, 
even  of  the  older  writers  on  medicine,  have  spoken  of  fevers  as  occurring 
among  children  at  all  ages  ;  but  under  this  name  they  confounded 
together  several  diseases  in  which  febrile  disturbance  was  merely  the 
effect  of  the  constitution  sympathizing  with  some  local  disorder.  This 
mistake  was  committed  with  especial  frequency  in  the  case  of  various 
affections  of  the  abdominal  viscera;  many  of  which  are  attended  by  a 
considerable  degree  of  sympathetic  fever,  while  their  symptoms,  in  other 
respects,  are  often  so  obscure  that  the  perfect  diagnosis  of  former  days 
failed  to  discover  their  exact  nature.  As  medical  knowledge  increased, 
many  of  these  disorders  were  referred  to  their  proper  place  ;  but,  never- 


444  INFANTILE   REMITTENT   FEVER. 

theless,  the  descriptions  given  of  the  so-called  remittent  fever,  worm 
fever,  and  hectic  fever  of  children,  present  little  of  a  definite  character, 
and  are  evidently  the  result  of  a  blending  together  of  the  symptoms  of 
various  affections.  The  disease  described  under  these  different  names 
was  supposed  to  be  a  symptomatic  fever,  excited  by  gastric  or  intestinal 
disorder,  and  limited  in  the  period  of  its  occurrence  to  early  life  ;  while 
the  absence  of  the  well-marked  shivering  which  usually  attends  the 
onset  of  fever  in  the  adult,  the  rarity  of  any  efflorescence  on  the  surface 
of  the  body,  and  the  comparatively  low  rate  of  mortality  which  it  occa- 
sions, led  persons  altogether  to  overlook  the  close  connection  between 
it,  and  the  continued  fever  of  the  adult. 

If,  however,  we  look  attentively  at  the  characters  of  this  disease, 
and  compare  them,  as  has  been  done  by  MM.  Rilliet  and  Barthez, 
with  those  presented  by  the  simple  continued  fever  of  the  adult,  we 
shall,  I  think,  see  so  close  a  correspondence  between  the  two  affections 
as  to  remove  all  doubt  with  reference  to  their  identity.  Both  diseases 
occur  independently  of  any  cause  which  we  are  able  to  detect ;  and 
both,  though  generally  affecting  isolated  individuals,  yet  have  also  their 
seasons  of  epidemic  prevalence.  Though  varying  in  severity,  so  that 
in  some  cases  confinement  to  bed  for  a  few  days  is  scarcely  necessary, 
while  in  other  cases  the  patient  hardly  escapes  with  his  life,  yet 
medicine  has  not  been  able  to  cut  short  the  course  even  of  their  mildest 
forms.  And,  lastly,  though  the  local  affections  associated  with  both 
vary  much  in  different  cases,  yet  in  every  instance  we  meet  with  that 
assemblage  of  symptoms  which  make  up  our  idea  of  fever.  Or  if,  from 
the  examination  of  the  symptoms  during  life,  we  pass  to  the  inquiry 
into  the  traces  left  by  the  disease  on  the  bodies  of  those  to  whom  it 
proves  fatal,  we  shall  find  still  further  evidence  of  the  close  relation 
that  subsists  between  the  fever  of  the  child  and  that  of  the  adult. 
Enlargement,  tumefaction,  and  ulceration  of  Peyer's  glands,  constitute 
one  of  the  most  frequent  morbid  appearances  m  both  diseases,  and  in 
both,  the  changes  that  these  glands  are  found  to  have  undergone  are 
more  advanced  and  more  extensive  in  proportion  to  their  nearness  to 
the  ileo-caecal  valve.  In  both,  too,  the  mesenteric  glands  are  enlarged, 
swollen,  of  a  more  or  less  deep  red  colour,  and  manifestly  increased 
in  vascularity;  while  the  softened  state  of  the  spleen,  the  gorged  con- 
dition of  the  lungs,  and  the  congestion  of  the  membranes  of  the  brain, 
are  appearances  common  to  both  diseases.  There  is,  however,  no 
more  relation  between  the  severity  of  the  intestinal  lesion  and  the 
intensity  of  the  symptoms  in  the  fever  of  the  child,  than  in  that  of 
the  adult ;  and  there  is  no  ground  for  regarding  the  disease  as  the 
mere  effect  of  the  constitution  sympathizing  with  a  certain  local  mis- 
chief in  the  former  case,  which  may  not  be  equally  alleged  with  refe- 
rence to  the  latter.  The  symptoms  in  both  "  are  the  expression  of 
the  influence  of  the  disease  on  the  whole  economy,  of  the  disorder, 
which  it  occasions  in  the  principal  functions  of  the  body,  and  are  an 
essential  part  of  the  disease  itself,  rather  than  the  secondary  effects  of 
certain  lesions  of  the  bowels."1 

J  Chomel,  Legonsde  Clinique  Medicalo  :  Fi£vre  Typhoide,  p.  231,  8vo.     Paris,  1834. 


SYMPTOMS   OP   ITS   MILDER   FORMS.  445 

There  are  still  many  questions  that  might  be  proposed  with  reference 
to  the  remittent  fever  of  children,  but  on  which  I  do  not  enter  now, 
because  I  am  at  present  unable  to  give  you  what  would  be,  even  to  my 
own  mind,  a  thoroughly  satisfactory  solution  of  them.  We  will,  there- 
fore, pass  at  once  to  a  safer  and  more  profitable  field  for  inquiry,  and 
will  examine  into  the  symptoms  that  characterize  this  aifection. 

The  different  degrees  of  severity  which  a  disease  may  present  in  dif- 
ferent cases  do  not  in  general  form  a  good  basis  on  which  to  found  any 
classification  of  its  varieties ;  but  in  the  case  of  the  remittent  fever  of 
children  the  differences  are  so  great  between  its  milder  and  its  severer 
form,  as  to  warrant  our  adopting  them  as  a  ground  for  a  subdivision  of 
the  disease  into  two  classes.  In  cases  of  the  first  or  milder  kind,  the 
disease  usually  comes  on  very  gradually,  often  so  much  so  that  the 
parents  of  a  child  who  is  attacked  by  it  are  unable  to  name  any  fixed 
time  as  that  at  which  the  illness  began.  The  child  loses  its  cheerful- 
ness, the  appearance  of  health  leaves  it,  the  appetite  fails,  and  the 
thirst  becomes  troublesome;  by  day-time  it  is  listless  and  fretful,  and 
drowsy  towards  evening>  but  the  nights  are  often  restless,  or  the  slumber 
broken  and  unrefreshing;  while  all  these  symptoms  come  on  without 
any  evident  cause,  and  are  not  accompanied  by  any  definite  illness. 
When  once  the  attention  of  the  parents  has  been  excited  to  the  condi- 
tion of  the  child,  it  is  soon  ascertained  that  the  skin  is  often  hotter,  and 
almost  always  drier  than  natural,  though  now  and  then  rather  profuse 
sweats  break  out  causelessly  on  the  surface,  and  continuing  for  an  hour 
or  two,  leave  the  patient  in  no  respect  relieved  by  their  occurrence. 
The  bowels  are  sometimes  loose  even  at  the  onset  of  the  disease,  or  if 
not,  they  are\in  general  readily  disturbed  by  medicine;  a  very  mild 
aperient  being  not  infrequently  followed  by  three  or  four  actions  of  the 
bowels  daily  for  the  next  two  or  three  days.  In  a  few  instances  there 
is  a  condition  of  rather  obstinate  constipation  at  the  onset  of  the  dis- 
ease, requiring  active  measures  to  overcome  it ;  but  this  is  not  often 
the  case,  and  when  it  does  occur,  it  is,  I  think,  more  frequently  in  the 
severer  than  in  the  milder  form  of  the  disease.  The  appearance  of  the 
evacuations  is  almost  always  unhealthy,  and  they  are  usually  relaxed 
and  very  offensive.  The  tongue  is  generally  rather  deficient  in  mois- 
ture, red  at  the  tip  and  edges,  thinly  coated  on  the  dorsum  with  white 
mucus,  through  which  the  papillae  appear  of  a  deep  red  colour.  The 
abdomen  is  soft,  though  there  is  some  flatus  in  the  intestines,  and  pres- 
sure is  usually  borne  without  pain.  These  characters  often  continue 
through  the  whole  course  of  the  affection,  though  sometimes,  after  the 
second  week,  pressure  in  either  iliac  region,  especially  the  right,  ap- 
pears to  cause  suffering.  The  pulse  is  generally  accelerated  from  the 
very  commencement  of  the  illness;  sometimes  it  is  very  much  so,  but 
there  is  by  no  means  a  constant  relation  between  the  heat  of  the  skin  and 
the  rapidity  of  the  pulse.  Occasionally  there  is  slight  cough,  but  this 
symptom  is  very  frequently  absent  in  the  milder  cases  of  the  disease. 
As  the  symptoms  which  constitute  this  affection  come  on  very  gradually, 
so  they  often  continue  for  several  days  with  little,  if  any,  change  from 
day  to  day,  though  the  patient  is  far  from  seeming  equally  ill  at  all 
times  of  the  day ;  and  this  periodical  exacerbation  and  remission  of  the 


446  SYMPTOMS   OF   THE    MILDER   FORM   OF  REMITTENT   FEVER. 

symptoms  has  obtained  for  the  disorder  the  name  of  remittent  fever. 
In  some  instances  two  distinct  exacerbations  and  remissions  may  be 
observed  in  the  course  of  every  twenty-four  hours,  but  in  the  majority 
of  cases  only  one  is  well  marked.  The  child,  who  during  the  day  has 
been  listless  and  poorly,  but  yet  not  incapable  of  being  amused,  and 
has  had  the  appearance  of  a  patient  convalescent  from  illness,  rather 
than  of  one  still  suffering  from  disease,  becomes  flushed  and  uneasy, 
and  feverish,  as  evening  approaches;  and  sometimes  slight  horripilation 
ushers  in  the  evening  exacerbation  of  fever.  The  child  seems  drowsy, 
and  begs  to  be  put  to  bed,  where  sometimes  he  sleeps,  though  seldom 
tranquilly,  till  morning.  In  the  second  week,  the  nights  generally 
become  worse  than  they  were  at  an  earlier  stage  of  the  disease ;  the 
child's  skin  is  very  dry  and  hot,  he  sleeps  with  his  eyes  half  open,  talks 
in  his  sleep,  wakes  often  to  ask  for  drink,  and  occasionally  has  slight 
delirium.  Early  in  the  morning  he  wakes  pale  and  unrefreshed,  but 
about  9  or  10  o'clock  seems  to  have  recovered  something  of  his  cheer- 
fulness, and  for  the  succeeding  three  or  four  hours  appears  tolerably 
well ;  but  as  evening  approaches  he  seems  weary  and  drowsy,  again 
the  febrile  paroxysm  occurs,  and  the  succeeding  night  closely  resem- 
bles the  night  before.  Sometimes,  in  addition  to  the  evening  exacer- 
bation, there  is  a  second  one,  though  less  severe,  at  about  11  o'clock  in 
the  morning ;  from  which  the  child  has  hardly  recovered  before  the 
severe  evening  attack  comes  on.  As  the  case  advances  towards  reco- 
very, the  morning  attack  disappears  long  before  the  evening  paroxysm 
ceases  to  recur ;  and  it  happens  not  infrequently  that  a  slight  threaten- 
ing of  the  evening  exacerbation  continues  to  return  for  some  time  after 
the  child  has  seemed  in  other  respects  well.  It  is  during  the  second 
week  of  the  disease  that  the  typhoid  eruption  generally  makes  its 
appearance,  if  it  appear  at  all.  In  the  milder  cases,  it  is,  I  believe, 
much  oftener  absent  than  present,  and  even  in  cases  of  a  severe  kind, 
it  is,  if  I  may  judge  from  my  own  experience,  much  less  common  in 
this  country  than  in  France.  Towards  the  end  of  the  second,  or  the 
beginning  of  the  third  week,  the  symptoms  begin  to  abate,  the  bowels 
act  more  regularly,  the  appearance  of  the  evacuations  becomes  more 
natural,  the  tongue  grows  cleaner  and  uniformly  moist,  the  thirst  dimi- 
nishes, and  the  evening  exacerbations  of  fever  become  shorter  and  less 
severe ;  while  the  child's  cheerfulness  by  day  returns,  and  its  face 
assumes  the  aspect  of  health.  Still,  after  even  a  mild  attack  of  this 
disease,  the  child  is  in  general  left  extremely  weak,  and  greatly  emaci- 
ated ;  the  loss  of  flesh  and  strength  being  quite  out  of  proportion  to  the 
severity  of  the  illness,  and  the  progress  to  complete  recovery  being 
generally  very  slow. 

It  sometimes  happens,  that,  having  set  in  with  comparatively  mild 
symptoms,  the  infantile  remittent  fever  assumes  a  serious  character  in 
the  course  of  the  second  week.  In  the  majority  of  instances,  however, 
the  severer  form  of  the  disease  gives  some  earnest  of  its  severity  at  a 
very  early  period.  It  commonly  sets  in  with  vomiting,  accompanied, 
in  many  cases,  by  headache,  or  by  a  remarkable  degree  of  drowsiness 
and  heaviness  of  the  head.  Coupled  with  these  symptoms,  there  are 
those  indications  of  fever  which  attend  the  milder  forms  of  the  disease, 


OF   ITS   SEVERER   FORxMS.  447 

though  in  this  case  with  a  proportionable  increase  in  their  severity :  and 
sometimes  distinct  rigors  may  be  observed  alternating  with  the  heat  of 
the  surface,  or  preceding  the  evening  exacerbations  of  the  fever.  In 
the  greater  number  of  instances,  the  vomiting  with  which  the  illness 
sets  in  does  not  return  after  the  second  or  third  day  of  the  patient's 
illness  ;  but  to  this  there  are  occasional  exceptions  ;  and  as  the  sickness 
is  usually  more  severe  in  cases  in  which  constipation  is  present,  there  is 
some  risk  of  mistaking  the  real  nature  of  the  affection,  and  of  regard- 
ing  the  irritability  of  the  stomach  as  a  sign  of  approaching  cerebral 
disease.  Now  and  then,  too,  the  drowsiness  at  the  onset  of  the  disease 
is  so  overwhelming  that  I  have  known  a  child  fall  asleep  two  or  three 
times  during  breakfast,  while  its  dizziness,  and  inability  to  walk  steadily, 
still  further  strengthened  the  impression  that  he  was  suffering  from 
some  affection  of  the  brain.  Either  of  these  occurrences,  however,  is 
unusual;  and,  though  listless  and  drowsy,  the  child  is  in  general  unwill- 
ing to  keep  his  bed,  while  by  night  he  is  commonly  very  restless,,  waking 
often  in  a  state  of  alarm,  or  talking  much  in  his  sleep.  The  counte- 
nance before  long  begins  to  wear  the  peculiar  heavy  appearance  of  a 
fever  patient,  and  by  the  end  of  the  first  or  the  beginning  of  the  second 
week  the  child  is  usually  found  to  have  sunk  into  a  state  of  stupor,  from 
which  he  seems  unwilling  to  be  roused.  The  skin  of  the  trunk  is  now 
almost  constantly  hot  as  well  as  dry  ;  the  temperature  being  often 
higher  than  in  any  other  disease,  with  the  exception  of  scarlatina,  and 
in  a  few  instances  ranging  as  high  as  105°  Fah.  My  own  observations 
wTith  reference  to  the  date  of  the  appearance  of  any  eruption  on  the 
surface  are  neither  sufficiently  numerous  nor  sufficiently  accurate  for 
me  to  rely  on\their  authority.  MM.  Rilliet  and  Barthez  observe  that 
it  very  seldom  appears  so  early  as  the  fourth  day,  from  the  sixth  to  the 
tenth  being  the  most  common  date  of  its  appearance;  while  both  the 
period  during  which  it  remains  visible,  and  the  number  of  spots,  are 
liable  to  great  variation.  In  by  far  the  greater  number  of  cases,  the 
eruption,  according  to  their  experience,  is  extremely  scanty  ;  it  often 
remains  visible  for  only  two  or  three  days,  and  in  not  a  few  instances  is 
absent  altogether.  In  a  few  cases  of  severe  remittent  fever,  profuse 
sweats  take  place,  but  they  do  not  seem  to  have  anything  of  a  critical 
character.  The  pulse  is  very  frequent,  and  I  have  known  it  to  con- 
tinue at  nearly  140  in  the  minute,  for  several  days  together,  during  the 
increase  of  the  fever  in  a  child  eight  years  old.  A  frequent,  short, 
hacking  cough  often  occurs  during  the  first  week  ;  and  rhonchus,  sibilus, 
and  occasional  large  crepitation,  are  heard,  in  many  cases,  in  both 
lungs.  Now  and  then,  too,  the  respiration  continues  much  accelerated 
for  several  days,  without  any  other  sign  of  serious  pulmonary  disease 
being  present,  and  gradually  regains  its  proper  frequency  as  the  febrile 
symptoms  subside.  Tenderness  of  the  abdomen  is  generally  very  evi- 
dent before  the  first  week  is  passed,  but  frequently  there  is  no  com- 
plaint of  pain,  even  in  severe  cases,  except  on  pressure.  Diarrhoea  is 
usually  present,  though  it  is  not  in  general  severe,  the  bowels  not  acting 
above  four  or  five  times  in  the  twenty-four  hours.  The  tongue  is 
usually  more  thickly  coated  at  the  commencement  than  in  the  milder 
forms  of  the  disease ;  a  dry  streak  soon  appears  down  the  centre,  and 


448  SYMPTOMS   OP   SEVERE   REMITTENT   FEVER. 

by  degrees  the  tongue  becomes  uniformly  dry,  red,  and  glazed  ;  or  less 
often  it  is  partially  covered  with  sordes.  In  the  course  of  the  second 
week  the  patient  generally  sinks  into  a  more  profound  stupor,  a  condi- 
tion which  alternates  in  many  cases  with  delirum.  Sometimes  the  mind 
wanders  occasionally  almost  from  the  commencement  of  the  disease,  in 
other  cases  delirum  is  a  very  temporary  symptom,  occurring  only  at 
night,  or  when  the  child,  during  the  day-time,  wakes  from  sleep.  Now 
and  then,  though  not  generally,  the  delirium  is  of  a  noisy  kind,  but  the 
child  iiot  infrequently  tries  to  get  out  of  bed  ;  and  both  the  restlessness 
and  delirium,  though  generally  present  in  bad  cases  during  the  daytime, 
are  aggravated  in  a  marked  degree  at  night.  Once  or  twice  I  have 
known  violent  delirium  come  on  towards  evening,  the  child  crying  and 
shouting  aloud  during  nearly  the  whole  night,  and  sinking  into  a  state 
of  stupor  by  day.  The  child  now  seems  nearly  or  quite  unconscious  of 
all  that  goes  on  around  it ;  its  evacuations  are  passed  unconsciously, 
and  it  often  seems  dead  to  the  sensation  of  thirst,  by  which,  in  the 
early  stages  of  the  disease,  it  was  so  much  distressed ;  but  this  stupor 
of  fever  is  so  different  from  the  coma  which  supervenes  in  affections  of 
the  brain,  and  the  insensibility  which  characterises  it  is  so  much  less 
profound,  that  one  can  hardly  be  mistaken  for  the  other.  Even  when 
the  disease  is  most  severe,  neither  subsultus  nor  floccitation  is  frequent, 
though  it  often  happens  that  during  the  tedious  and  fluctuating  conva- 
lescence the  child  picks  its  nose  till  it  bleeds,  or  makes  the  tips  of  its 
fingers,  or  different  parts  of  its  body,  sore  by  picking  them.  The  pa- 
tient is  by  the  end  of  the  second  week,  sometimes  earlier,  reduced  by 
the  continuance  of  these  symptoms  to  the  most  extreme  degree  of  ema- 
ciation, and  to  a  condition  apparently  hopeless  ;  but  there  is  no  disease 
from  which  recovery  so  often  takes  place,  in  spite  of  even  the  most 
unfavourable  systems,  as  from  remittent  fever.  The  signs  of  recovery 
are,  in  the  main,  the  same  as  betoken  the  recovery  of  an  adult  suffer- 
ing from  fever,  but  the  amendment  has  seemed  to  me  always  to  be 
gradual,  and  in  no  case  the  result  of  any  critical  occurrence.  Moisture 
begins  to  reappear  upon  the  edges  of  the  tongue,  the  pulse  loses  its 
frequency,  the  delirium  ceases  by  degrees,  more  quiet  rest  is  enjoyed  at 
night.  Such  signs  of  improvement  may  in  general  be  looked  for  about 
the  end  of  the  second  week,  but  often  the  patient's  progress  is  inter- 
rupted by  many  fluctuations ;  the  convalescence  is  almost  always  slow, 
and  relapses  occur  from  very  slight  causes. 

In  the  few  cases,  and  according  to  my  experience  they  are  but  few, 
in  which  remittent  fever  terminates  fatally,  death  is  seldom  the  result 
of  complications  such  as  not  infrequently  supervene  in  the  course  of 
fever  in  the  adult,  but  the  vital  powers  give  way  under  the  severity  of 
the  constitutional  affection,  the  symptoms  of  which  assume  more  and 
more  of  a  typhoid  character.  It  is  towards  the  end  of  the  second,  or  at 
the  beginning  of  the  third  week,  that  death  under  these  circumstances 
is  most  likely  to  occur ;  I  have  seen  it  take  place  as  late  as  the  twenty- 
ninth  day  in  one  instance,  and  at  the  end  of  the  fifth  week  in  another, 
but  in  both  of  these  instances  gangrene  of  the  mouth  came  on  after  the 
more  alarming  general  symptoms  had  begun  to  subside  ;  and  to  this  the 
death  of  the  child  was  chieily  due.    Now  and  then  a  fatal  termination 


DIAGNOSIS   OF   THE   DISEASE.  449 

takes  place  after  the  lapse  of  little  more  than  a  week  from  the  com- 
mencement of  the  illness,  under  signs  of  cerebral  disturbance  which 
throw  the  general  febrile  symptoms  into  the  shade ;  great  restlessness 
and  agitation,  with  loud  cries,  being  succeeded  by  convulsions,  and 
they,  in  their  turn,  being  followed  by  coma,  in  which  the  child  dies  ; 
while  an  examination  after  death  discovers  nothing  more  serious  than 
a  somewhat  greater  vascularity  than  natural  of  the  brain  and  its 
membranes. 

The  diagnosis  of  remittent  fever,  has  been  rendered  needlessly  diffi- 
cult by  the  loose  manner  in  which  the  name  has  been  applied  to  a 
variety  of  affections ;  still  it  must  be  confessed  that  there  are  several 
diseases,  between  which,  and  remittent  fever,  there  are,  in  some  parts 
of  their  course,  points  of  similarity  that  may  easily  deceive  the  unwary. 
The  resemblance  is  often  very  close  between  the  milder  varieties  of  the 
fever  and  some  of  those  cases  of  gastro-intestinal  disorder,  by  no  means 
unusual  in  young  children,  which  are  excited  by  errors  of  diet,  and  are 
either  associated  with  diarrhoea  or  preceded  by  it.  Even  in  such  cases, 
however,  the  loss  of  strength,  the  dry  heat  of  the  skin,  and  its  intensity 
at  the  time  of  the  exacerbations  of  the  fever,  the  marked  disturbance 
of  the  sensorium,  and  the  delirium  at  night,  which  is  almost  always 
present  in  children  sufficiently  old  for  this  symptom  to  be  apparent,  are 
characters  by  which  remittent  fever  may  generally  be  known.  General 
tubercular  disease,  running  an  acute  course,  may  now  and  then  be 
taken  for  a  short  time  for  remittent  fever ;  but  the  observation  of  the 
case  for  a  few  days  will  usually  suffice  to  correct  the  error.  In  most 
instances  ofxthe  former  affection,  indeed,  the  possibility  of  mistake  is 
altogether  prevented  by  the  skin  being  less  hot,  the  sensorium  not  dis- 
turbed, and  the  abdominal  symptoms  slighter  than  they  might  be 
expected  to  be  in  a  case  of  remittent  fever  of  the  same  degree  of 
severity.  Independently  of  this,  too,  auscultation  will  often  shew  good 
reason  for  suspecting  the  real  nature  of  the  case,  or  the  previous  history 
of  the  child  will  afford  some  clue  with  reference  to  it.  There  are  two 
other  affections  between  which  and  remittent  fever  it  is  often  far  from 
easy  to  distinguish,  while,  unfortunately,  the  practical  evils  that  follow 
from  a  wrong  diagnosis  are  of  a  very  serious  nature.  When  speaking, 
however,  of  hydrocephalus  and  of  pneumonia,1  I  dwelt  so  fully  upon 
the  circumstances  that  might  lead  you  to  mistake  either  of  those 
diseases  for  remittent  fever,  and  of  the  characteristics  which  belong  to 
the  last-named  affection,  that  it  can  scarcely  be  necessary  to  do  more 
than  refer  you  to  the  observations  made  on  those  occasions. 

I  am  anxious,  however,  before  we  pass  to  the  treatment  of  the  disease, 
to  guard  against  an  error  which  may  possibly  arise,  from  my  having 
pointed  out  certain  well-marked  distinctions  between  the  cerebral 
symptoms  of  hydrocephalus  and  those  which  accompany  remittent  fever. 
Now,  although  it  is  perfectly  true  that  the  disturbance  of  the  brain  in 
the  latter  case  is  the  result  of  mere  functional  disorder,  which,  with  the 
abatement  of  the  fever,  will,  in  general,  by  degrees  pass  away,  still  it 
is  not  to  be  forgotten  that  serious,  and  even  fatal,  cerebral  affection 

1  See  Lecture  YI.  p.  72 ;  and  Lecture  XVII.  p.  198. 
29 


450  DIAGNOSIS   OP   REMITTENT   FEVER. 

occasionally  attends  it.  It  is  not  indeed,  commonly  at  an  early  stage 
of  the  fever  that  we  need  be  anxious  on  this  account,  for  dangerous 
cerebral  complications  seldom  occur  before  the  middle  of  the  second 
week,  sometimes  even  later ;  while  now  and  then  they  succeed  to  a  sort 
of  imperfect  convalescence,  from  the  signs  of  which  we  had  already 
begun  to  hope  that  the  most  anxious  period  was  passed.  The  indica- 
tions of  their  supervention  are  various,  and  often  of  such  a  kind  as, 
considering  the  character  of  the  child's  previous  illness,  may  fail  to 
excite  that  attention  which  otherwise  they  would  attract.  The  more 
than  ordinary  excitability  of  the  patient,  the  peculiar  noisiness  of  his 
delirium,  and  the  ungovernableness  of  his  temper,  should  arouse  our 
suspicions,  even  in  the  case  of  an  ill-managed  and  wayward  child,  in 
wThom  these  symptoms  may  in  part  be  due  to  mere  petulance.  Some- 
times, however,  the  mode  of  approach  of  serious  head  mischief  is  even 
more  treacherous.  The  fever  has  already  abated,  the  tongue  has 
grown  somewhat  moister,  the  delirium  is  less  constant,  the  restlessness 
less  distressing,  and  the  child  even  has  some  quiet  sleep  ;  but  he  lies  often 
grinding  his  teeth,  or  there  is  frequent  machonnement,  or  slight 
twitchings  of  the  facial  muscles  occur  occasionally.  The  eyes  grow 
less  intolerant  of  light,  and  as  the  child  opens  them  once  more,  the 
parents  please  themselves  with  its  fancied  improvement,  fondly  imagining 
that  it  looks  around  and  notices  again.  The  pupils,  however,  are  more 
dilated  than  natural,  and  act  more  sluggishly;  the  pulse  presents  a 
slight  irregularity  or  intermission ;  sensibility  to  external  objects  lessens  ; 
and  coma  steals  on  almost  imperceptibly,  though  death  is  sometimes 
preceded  by  convulsions,  while  in  other  cases  all  the  symptoms  of 
hydrocephalus  by  degrees  develop  themselves. 

The  unobserved  supervention  of  pneumonia  is  guarded  against  by 
daily  careful  auscultation  :  the  existence  of  diarrhoea  tells  too  plainly  of 
the  abdominal  complication  for  that  to  be  overlooked ;  but  when  so 
much  disturbance  of  the  nervous  system  is  part  and  parcel  of  the  affec- 
tion, some  excess  of  it  may  readily  pass  without  due  importance  being 
attached  to  it.  When,  then,  you  may  ask,  are  we  to  become  anxious 
about  the  head  ?  I  should  say,,  whenever  delirium  is  present,  not  merely 
during  the  night,  or  on  waking  from  slumber  in  the  day-time,  but 
whenever  it  also  continues  during  the  day,  or  when  there  is  during  the 
day  an  extremely  excitable  and  unmanageable  condition,  though  not 
amounting  to  actual  delirium.  Or,  secondly,  whenever,  with  the 
abatement  of  the  fever,  the  cerebral  symptoms  do  not  diminish  in 
proportion ;  or  some  new,  even  though  very  slight,  indication  of  disor- 
der of  the  nervous  system  appears,  although  the  excitement  manifest 
in  the  earlier  stages  of  the  affection  may  have  almost  or  altogether 
passed  away.  These  symptoms  may,  indeed,  speedily  subside,  or  they 
may  yield,  and  probably  will,  to  judicious  treament,  but  they  indicate 
a  source  of  danger  against  which  tyou  cannot  be  too  carefully  or  too 
unceasingly  on  the  watch.  at* 

Thus  much  concerning  the  disease ;  now,  in  conclusion,  as  to  its 
treatment.  In  the  management  of  remittent  fever  in  the  child,  just  as 
of  fever  in  the  adult,  the  grand  object  to  which  our  attention  ought  to 
be  turned  is  to  carry  the  patient  through  an  affection  which  we  cannot 


ITS   TREATMENT.  451 

cut  short,  with  as  small  an  amount  of  suffering  or  danger  as  possible. 
"  Medieus  curat,  natura  sanat  morhum"  says  an  old  Latin  adage;  and 
in  no  disease  is  it  of  so  much  importance  as  in  fever,  that  we  should 
assign  to  our  art  its  proper  position  as  the  handmaid  of  nature.  The 
gradual  approach  of  the  disorder,  in  the  great  majority  of  instances, 
of  itself  points  out  the  propriety  of  that  expectant  mode  of  treatment 
which  is  generally  the  most  appropriate  during  the  first  week  of  the 
child's  illness.  The  languid  and  listless  state  of  the  little  patient,  his 
headache  and  drowsiness,  often  lead  him  to  wish  to  remain  in  bed  all 
day  long ;  but  there  is  no  reason  for  confining  him  to  bed,  if,  during 
the  period  of  remission  of  the  fever,  he  should  prefer  to  sit  up.  The 
impaired  appetite  often  renders  any  other  directions  about  the  diet 
unnecessary,  than  a  caution  to  the  parents  or  nurse  not  to  coax  or 
tempt  the  child  to  take  food,  which  it  is,  and  will  probably  for  some 
days  continue  to  be,  entirely  unable  to  digest.  The  heat  of  skin 
and  the  craving  thirst  are  the  two  most  urgent  symptoms  in  the  early 
stages  of  the  affection.  The  first  of  these  is  generally  relieved  by  the 
tepid  bath  at  90°  or  92°  every  morninpr,  and  by  sponging  the  surface 
of  the  body  several  times  a  day  with  lukewarm  water.  The  desire  for 
cold  drinks  is  often  very  urgent,  and  no  beverage  is  half  so  grateful  as 
cold  water  to  the  child.  Of  this  it  would,  if  permitted,  take  abundant 
draughts ;  but  it  should  be  explained  to  the  attendants  that  the  thirst 
is  not  more  effectually  relieved  by  them  than  by  small  quantities  of 
fluid,  while  pain  in  the  abdomen  is  very  likely  to  be  caused  by  the  over- 
distention  of  the  stomach.  The  cup  given  to  the  child  should  therefore 
only  have  a\dessert  or  table-spoonful  of  water  in  it,  for  it  irritates  the 
little  patientX  to  remove  the  vessel  from  its  lips  unemptied.  In  the 
milder  forms  of  the  disease,  and  during  the  first  week,  medicine  is  little 
needed;  but  a  simple  saline  may  be  given,  such  as  the  citrate  of  potass 
in  a  mixture  to  which  small  doses  of  vinum  ipecacuanha  may  be  added, 
if,  as  sometimes  happens,  the  cough  be  troublesome.  If  the  bowels  act 
with  due  frequency,  and  the  appearance  of  the  evacuations  be  not 
extremely  unhealthy,  it  is  well  to  abstain  from  the  employment  of  any 
remedy  which  might  act  upon  them,  for  fear  of  occasioning  diarrhoea, 
which  is  so  apt  to  supervene  in  the  course  of  this  affection.  For  the 
same  reason,  if  an  aperient  be  indicated,  drastic  purgatives  are  not  to 
be  given,  but  a  moderate  dose  of  castor  oil  should  be  administered. 
Now  and  then,  however,  cases  are  met  with  in  which  the  bowels  remain 
confined  during  a  great  part  of  the  affection,  and  in  which  such  purga- 
tives as  senna  are  not  only  borne,  but  absolutely  necessary.  They 
however,  are  purely  exceptional  cases ;  and  it  will  generally  suffice,  if 
there  exists  any  tendency  to  constipation,  to  give  a  small  dose  of  the 
mercury  and  chalk  night  and  morning,  and  during  the  day-time  a  small 
quantity  of  the  tartrate  of  soda  or  sulphate  of  magnesia,  dissolved  in 
some  simple  saline  mixture,  every  six  or  eight  hours. 

The  unhealthy  state  of  the  evacuations  that  exists  in  a  large  number 
of  cases  is  generally  associated  with  a  disposition  to  diarrhoea,  which 
becomes  a  more  prominent  symptom  in  the  second  than  it  was  in  the 
first  week  of  the  disorder.     Equal  parts  of  the  hydrargyrum  cum  cret& 


452  OF   HEAD   SYMPTOMS   BY  ANTIMONY  AND   OPIUM. 

and  Dover's  powder  are  the  best  means  of  relieving  both  these  morbid 
conditions ;  the  remedy  being  given  either  once  or  twice  a  day,  or  more 
frequently,  according  to  the  urgency  of  the  symptoms.  The  amount  of 
abdominal  pain  and  tenderness  must  be  ascertained  every  day  ;  and  a 
few  leeches  must  be  applied  to  either  iliac  region  if  the  tenderness  seem 
considerable,  or  if  the  child  appear  to  suffer  much  from  pain  in  the 
abdomen,  or  if  the  diarrhoea  be  severe.  If  depletion  be  needed,  the 
application  of  but  a  small  number  of  leeches  will  generally  meet  the 
requirements  of  the  case,  while  copious  bleeding  is  neither  useful  nor 
well  borne.  Even  in  children  of  ten  years  old  I  never  apply  above  four 
or  six  leeches,  and  it  is  very  seldom  that  any  occasion  arises  for  a 
repetition  of  the  bleeding.  The  application  of  poultices  of  linseed  meal 
or  scalded  bran  to  the  abdomen,  and  their  frequent  repetition,  is  a  very 
valuable  means  of  relieving  the  griping  pain  which  often  distresses 
children ;  and  in  most  cases  it  is  desirable  to  make  trial  of  them  before 
having  recourse  to  depletion. 

There  is  but  one  other  class  of  symptoms  likely  to  occur  during  the 
first  week  of  the  fever,  to  the  management  of  which  I  have  not  yet 
referred ;  namely,  those  signs  of  cerebral  disturbance  which  are  some- 
times so  serious  as  to  call  for  treatment.  The  early  occurrence  of 
delirium,  though  it  generally  implies  that  the  disease  will  assume  a 
rather  serious  character,  yet  does  not  of  itself  indicate  the  necessity  for 
taking  blood  from  the  head ;  but  if  the  child  be  quiet  and  generally 
rational  during  the  day-time,  and  though  dull  yet  not  in  a  state  of 
stupor,  while  the  delirium  at  night  is  of  a  tranquil  kind,  and  inter- 
rupted by  frequent  and  tolerably  quiet  slumber,  it  will  generally  suffice  to 
apply  cold  to  the  head,  and  to  keep  the  apartment  cool  and  absolutely 
quiet.  The  irritability,  excitability,  and  restlessness  at  night,  accom- 
panied by  loud  and  noisy  delirium,  from  which  the  child  gets  scarcely 
any  respite  all  night  long,  are  frequently  arrested  at  once  by  an  opiate. 
Unless  some  abdominal  complication  should  forbid  its  employment,  the 
tartar  emetic  is  in  these  cases  a  most  valuable  adjunct  to  the  opium.1 
A  draught  containing  five  minims  of  laudanum,  and  a  quarter  or  a 
third  of  a  grain  of  tartar  emetic,  will  be  a  suitable  anodyne  for  a  child 
of  five  years  old,  and  may  be  repeated  night  after  night  with  almost 
magical  effect.  When  the  delirium  at  night  is  succeeded  during  the  day- 
time by  an  almost  equally  distressing  condition  of  excitement,  accom- 
panied with  a  burning  skin,  and  a  very  frequent  though  feeble  pulse, 
the  continuing  the  tartar  emetic  in  slightly  nauseating  doses,  combined 
with  smaller  quantities  of  laudanum,  every  four  hours,  will  often  be  of 
essential  service.  If,  however,  there  be  any  injection  of  the  conjunc- 
tivae, or  if  the  head  be  in  a  marked  degree  hotter  than  the  surface 
generally,  or  if  any  other  indication  of  disorder  of  the  brain  be  present 
besides  the  delirium  and  excitement,  leeches  should  be  applied  to  the 
head, — though  depletion  should  in  these  cases  be  used  sparingly  ;  and 
after  the  abstraction  of  blood  by  the  application  of  half  a  dozen  leeches, 

1  The  remarks  of  Dr.  Graves,  in  his  Lectures  on  Clinical  Medicine,  vol.  i.  p.  207,  on 
the  use  of  Tartar  Emetic  and  Opium  in  Fever,  are  little  less  applicable  to  its  manage- 
ment in  the  child  than  in  the  adult. 


TREATMENT   03T   HEAD    SYMPTOMS — DEPLETION.  453 

we  should  return  to  the.tart.ar  emetic  and  opium,  remembering  that 
we  have  no  active  inflammation  to  combat,  nor  even  that  intense 
cerebral  congestion  which  we  occasionally  meet  with  under  other  cir- 
cumstances, and  safety  from  which  is  found  only  in  very  active 
depletory  measures. 

Depletion  is  also  called  for  in  cases,  not  very  commonly  met  with,  in 
which  even  at  an  early  period  of  the  disease  there  is  a  great  degree  of 
stupor,  and  apathy,  with  a  dilated  and  sluggish  pupil,  but  little  com- 
plaint of  thirst,  and  none  of  headache  or  local  suffering.  By  the  cautious 
abstraction  of  blood  we  may  here  sometimes  anticipate  the  development 
of  the  more  alarming  head  symptoms,  which,  if  we  leave  the  patient 
alone,  lulled  into  a  false  security  by  the  absence  of  any  signs  of  active 
mischief,  will  not  fail  before  long  to  manifest  themselves.  As  a  general 
rule,  indeed,  it  must  be  our  object  in  the  management  of  this  fever  to 
anticipate  the  head  symptoms  as  far  as  possible,  to  keep  down  the 
excitement  and  quiet  the  delirium  by  tartar  emetic  and  opium,  or  by 
the  local  abstraction  of  blood  :  a  purely  expectant  course  of  practice  is 
neither  wise  nor  safe.  The  head  symptoms,  which  come  on  slowly  and 
almost  imperceptibly  at  a  more  advanced  stage  of  the  disease,  are  some- 
times very  unmanageable.  Depletion  is  no  longer  of  service,  but  blisters 
may  be  applied  to  the  occiput  and  nape  of  the  neck  with  advantage ; 
they  should,  however,  not  be  kept  on  so  long  as  to  produce  complete 
vesication,  but  only  for  a  time  sufficient  to  obtain  their  counter-irritant 
effect,  and  to  allow  of  their  reapplication  in  the  same  neighbourhood,  if 
not  upon  exactly  the  same  spot,  on  the  next  day.  The  unfavourable 
termination^ of  the  disease  in  this  stage  is,  I  apprehend,  due,  in  the 
great  majority  of  cases,  to  the  development  of  some  previously  latent 
tendency  to  tubercular  hydrocephalus;  while  the  more  active  head 
symptoms,  which  are  met  with  at  an  earlier  period,  are  often  merely 
the  result  of  functional  disturbance,  and  therefore  often  yield  to  well- 
considered  treatment. 

In  mild  cases  of  the  disease,  the  expectant  treatment,  usually  appro- 
priate during  its  early  stages,  may  be  continued  throughout  its  course ; 
great  caution  being  exercised,  as  the  child  begins  to  improve,  to  prevent 
its  committing  any  error  in  diet.  When  severe,  however,  the  second 
week  often  brings  with  it  a  train  of  symptoms  that  require  many 
modifications  in  the  plan  of  treatment.  The  vital  powers  need  to  be 
supported,  and  the  nervous  system  requires  to  be  tranquillized ;  and  this 
is  to  be  attempted  by  means  similar  to  those  which  we  should  employ 
in  the  management  of  fever  in  the  adult.  The  mere  diluents  which 
were  given  during  the  previous  course  of  the  fever  must  now  be 
exchanged  for  beef  or  veal  tea  or  chicken  broth,  unless  the  existence 
of  severe  diarrhoea  contraindicate  their  administration  ;  in  which  case 
we  must  substitute  arrow  root,  milk,  and  isinglass,  for  animal  broths. 
In  a  large  proportion  of  cases  nutritious  food  is  all  that  will  be  required; 
but  wine  is  sometimes  as  essential  as  in  the  fevers  of  the  adult ;  and 
the  indications  for  giving  it  are  much  the  same  in  patients  of  all  ages. 
Even  though  wine  be  not  necessary,  I  generally  give  some  form  of 
stimulant  during  the  second  and  third  weeks  of  the  affection.     The 


454  TREATMENT  OP  REMITTENT  FEVER. 

prescription1  which  I  usually  follow  is   one  inuch  praised  under  such 

(No.  34.) 
1  J&  Acid.  Hydrochlor.  dil.  ttl^xxxij. 
Spt.  iEth.  Sulpb.  co.  3J.  tt^xx. 
Syr.  Rhseados,  giv. 

Mist.  Camph.  ^iiiss.     M.     giv.  6tis  horis. 
For  a  child  five  years  old. 

circumstances  by  Dr.  Stieglitz,  of  St.  Petersburgh,  the  chief  ingre- 
dients of  which  are  ether  and  hydrochloric  acid.  It  seldom  disorders 
the  bowels  if  they  be  not  much  disturbed  at  the  time  of  commencing 
its  administration ;  while,  if  this  be  the  case,  a  small  dose  of  Dover's 
powder,  as  a  grain  or  a  grain  and  a  half  at  bed-time,  will  be  doubly 
useful,  both  in  checking  the  tendency  to  diarrhoea,  and  in  procuring 
sleep  for  the  child,  who,  without  it,  would  probably  be  watchful  and 
delirious  all  night  long.  While  any  severe  abdominal  symptoms  are 
present,  I  abstain  from  the  use  of  the  acid  mixture,  but  give  the  mer- 
cury with  chalk,  and  Dover's  powder,  every  four  or  six  hours,  to  which 
I  occasionally  add  an  opiate  enema  at  bed-time,  and  support  the 
strength  by  food  and  wine  as  may  be  necessary. 

The  only  complication  that  is  apt  to  be  troublesome  is  the  bronchitis. 
Usually,  however,  the  cough  to  which  this  gives  rise  is  an  annoying 
rather  than  a  dangerous  symptom  ;  and  it  is  in  general  more  harassing 
at  the  commencement  of  the  affection,  and  again  when  convalescence 
is  beginning,  than  during  that  time  when  the  graver  symptoms  are  pre- 
sent. A  little  ipecacuanha  wine,  nitrous  ether,  and  compound  tincture 
of  camphor,  will  usually  relieve  it,  to  which  it  may  occasionally  be 
expedient  to  add  the  application  of  a  mustard  poultice  to  the  chest. 

The  convalescence  is  often  extremely  tedious  ;  the  child  is  left  by  the 
disease  not  only  extremely  weak  and  emaciated,  but  with  its  digestive 
powers  greatly  impaired.  It  is  often  many  days  before  the  stomach  is 
able  to  digest  any  solid  food ;  even  a  piece  of  bread  will  sometimes 
irritate  the  intestines,  and  bring  on  a  return  of  diarrhoea.  The  appe- 
tite seems  sometimes  quite  lost;  tonics  either  do  no  good,  or  are  actu- 
ally injurious  by  rekindling  the  fever ;  or  symptoms  supervene  which 
seem  to  threaten  the  development  of  tubercular  disease,  a  consequence 
that  not  very  seldom  follows  severe  attacks  of  remittent  fever.  Under 
such  circumstances,  change  of  air,  and  the  removal,  if  possible,  to  the 
sea-side,  are  often  the  only  means  of  restoring  the  child  to  health ;  a 
means  which  you  may  recommend  with  the  more  confidence  since  it 
hardly  ever  fails  to  be  successful. 


SMALL-POX.  455 


LECTUEE    XXXVIII. 

Small  pox — checked  but  not  extirpated  by  vaccination — its  chief  mortality  among  chil- 
dren— rate  of  mortality  in  cases  of  the  disease  undiminished  during  the  last  fifty 
years. — Its  symptoms — their  early  differences  from  those  of  the  other  exanthemata — 
characters  and  progress  of  the  eruption — peculiarities  of  confluent  small-pox — dangers 
attending  the  maturation  of  the  pustules,  and  the  secondary  fever. — Treatment. 

Modified  small  pox — its  low  rate  of  mortality — its  peculiarities. 

Chicken-pox — its  symptoms,  and  differences  from  small-pox. 

Until  the  commencement  of  this  century,  the  disease  to  which  I 
•wish  to-day  briefly  to  call  your  attention  possessed  a  degree  of  impor- 
tance far  greater  than  that  which  attaches  to  it  at  present.  Before  the 
introduction  of  vaccination,  the  small-pox  was  a  disease  of  almost  uni- 
versal prevalence,  causing  at  the  least  eight  per  cent,  of  the  total  mor- 
tality of  this  metropolis,  and  disfiguring  for  life  thousands  whom  it  did 
not  destroy.  Its  loathsome  character,  and  its  formidable  symptoms 
when  it  attacked  the  constitution  at  unawares,  led  to  the  adoption  of 
variolous  inoculation,  by  which  the  disease  was  communicated  in  a  mild 
form,  and  under  favourable  conditions  ;  and  persons  having  undergone 
comparatively  little  suffering,  and  having  been  exposed  to  still  less 
danger,  enjoyed  by  this  means  almost  complete  immunity  from  subse- 
quent attacks  of  small-pox.  But,  great  as  its  benefits  were,  variolous 
inoculation  perpetuated  at  all  times,  and  in  all  places,  a  disease  which 
would  otherwise  have  obeyed  the  general  law  of  epidemics,  and  would 
have  had  its  periods  of  rare  occurrence  as  well  as  those  of  wide-spread 
prevalence.  Thus,  as  has  been  well  observed,  while  the  advantages  of 
the  practice  were  great  and  obvious  to  the  individual,  to  the  community 
at  large  they  were  very  doubtful. 

No  such  drawback  exists  to  detract  from  the  benefits  of  vaccination, 
though  unfortunately  our  present  experience  does  not  altogether  justify 
the  sanguine  expectations  entertained  concerning  it  by  its  first  promo- 
ters. Peculiarities  of  climate  oppose  a  serious  barrier  to  its  successful 
introduction  into  some  countries,1  and  even  in  our  own  land  individuals 
are  occasionally  met  with  in  whom  vaccination  altogether  fails,  or  over 
whom  it  seems  to  extend  but  a  partial  or  a  temporary  protective  power. 

But  I  will  not  enter  on  the  question  of  the  merits  of  vaccination, nor 
of  the  circumstances  that  impair  its  preservative  power,  or  call  for  its 
repetition  :  for  though  the  subject  is  one  important  alike  to  the  physi- 
cian and  the  philanthropist,  I  have  had  no  opportunities  of  forming  a 
judgment  concerning  it  which  are  not  alike  open  to  you  all.  In  the 
writings  of  Dr.  Gregory,  physician  to  the  Small-Pox  Hospital,  and  in 
the  treatise  on  vaccination  by  Dr.  Steinbrenner,  to  which  the  Institute 

1  Dr  Duncan  Stewart's  valuable  Report  on  Small-Pox  in  Calcutta,  and  Vaccination  in 
Bengal,  8vo.,  Calcutta,  1844,  shews  conclusively  that  the  peculiarities  of  the  Indian 
climate  present  obstacles  to  vaccination  such  as  greatly  to  detract  from  its  value  ;  while 
it  is  to  be  feared  that  they  are  of  a  nature  which  the  greatest  care  will  never  wholly 
overcome. 


456  SMALL-POX. 

of  France  adjudged  a  prize  in  1835,  you  will  find  everything  that  either 
large  experience  or  unwearied  research  can  bring  to  its  elucidation. 

One  fact  which  it  behoves  us  always  to  bear  in  mind,  is,  that  albeit 
the  prevalence  of  the  disease  has  been  greatly  checked  by  vaccination, 
small-pox  is  still  one  of  the  most  fatal  maladies  of  this  country  ;  and 
further,  that  it  selects  its  victims,  as  heretofore,  chiefly  from  among 
children  and  young  persons, — nearly  three-fourths  of  the  fatal  cases  of 
this  affection  occurring  before  the  age  of  five,  and  more  than  nine- 
tenths  before  the  age  of  fifteen  years.  In  spite,  too,  of  the  increase 
of  medical  knowledge  during  the  past  fifty  years,  the  proportion  of 
small-pox  cases  that  terminate  fatally  has  been  estimated  by  the  best 
authorities  to  be  as  great  now  as  it  was  half  a  century  ago;  To  some 
extent,  perhaps,  the  very  diminution  in  the  frequency  of  the  disease 
may  have  had  an  unfavourable  influence  on  its  issue  in  individual  cases  ; 
for  practitioners,  meeting  with  it  now  less  often  than  medical  men  in 
former  days  were  wont  to  do,  are  not  so  familiar  with  the  meaning  of 
those  minuter  variations  in  its  symptoms,  from  which  important  practi- 
cal conclusions  might  be  drawn,  by  those  who  knew  how  to  interpret 
them  aright. 

Let  me  therefore  urge  you  to  watch  every  case  of  this  formidable 
disease  that  may  come  under  your  observation  with  most  minute  care, 
lest  you  misinterpret  the  symptoms,  or  mistake  the  treatment  of  some 
patient  affected  with  it,  whose  wTell-being  may  be  dependent  on  your 
skill.  For  my  own  part,  I  cannot  pretend  to  give  you  more  than  an 
outline  sketch  of  its  characters,  and  must  refer  you  to  the  writings  of 
others  who  have  had  greater  opportunities  of  watching  it  than  have 
fallen  to  my  share,  to  fill  up  the  portrait. 

The  early  symptoms  of  small-pox  are  those  of  approaching  fever,  and 
if  any  other  febrile  disorder  be  prevalent  at  the  time  of  their  occurrence 
they  may  possibly  be  taken  for  the  indications  of  an  approaching  attack 
of  the  prevailing  epidemic.  There  are,  however,  some  peculiarities  in 
the  mode  of  onset  of  small-pox  which  are  sufficiently  characteristic  of 
it  even  in  the  child,  and  which  generally  distinguish  it  from  either  of 
the  other  eruptive  fevers.  The  sickness  with  which  it  sets  in  is  in  gen- 
eral severe,  and  the  disorder  of  the  stomach  often  continues  for  forty- 
eight  hours,  during  which  time  vomiting  recurs  frequently.  In  measles 
there  is  comparatively  little  gastric  disorder ;  and  the  vomiting  that 
often  ushers  in  scarlatina,  though  frequently  severe,  is  not  of  such  long 
continuance.  In  young  children  we  lose  those  complaints  of  intense 
pain  in  the  back  which  in  the  case  of  older  patients  often  awaken  our 
suspicion  ;  but  on  the  other  hand,  the  severity  of  the  cerebral  distur- 
bance is  an  important  feature  in  the  early  stage  of  the  disease.  At  the 
commencement  of  measles,  the  brain  is  in  general  but  little  disturbed ; 
in  scarlatina,  delirium  often  occurs  very  early  ;  but  in  small-pox  the 
condition  is  one  rather  of  stupor  than  of  delirum,  while  convulsions 
sometimes  take  place,  and  continue  alternating  with  coma  for  as  long  a 
period  as  "twenty-four  or  thirty-six  hours.  Lastly,  though  the  skin  in 
small-pox  is  hot,  it  is  neither  so  hot  nor  so  dry  as  in  scarlet  fever  ;  the 
tongue  does  not  present  the  peculiar  redness,  nor  the  prominence  of  its 
papillge,  which  are  observable  in  scarlatina ;  neither  is  there  any  of  the 


ITS   SYMPTOMS.  457 

sore-throat  which  forms  so  characteristic  a  symptom  of  that  disease. 
The  early  stages  of  small-pox  are  not  attended  with  the  catarrhal 
symptoms  which  accompany  measles  ;  the  eruption  of  measles  usually 
appears  later,  that  of  scarlet  fever  always  sooner,  than  the  eruption  of 
small-pox;  while  its  papular  character  is  in  general  sufficiently  well 
marked  to  distinguish  it  from  the  rash  of  either  of  those  diseases.  It 
never  appears  in  less  than  forty-eight  hours  from  the  first  sign  of  in- 
disposition, often  not  till  after  a  somewhat  longer  time.  It  shews  itself 
in  the  form  of  small  papulae,  which  are  first  discernible  on  the  face, 
forehead,  and  wrists,  whence  they  extend  to  the  trunk  and  arms,  and 
lastly  to  the  lower  extremities.  These  papulae  are  at  first  slightly  red, 
somewhat  acuminated  elevations,  so  minute  that  they  may  be  easily 
overlooked  on  a  hasty  examination,  but  yet  conveying  a  distinct  sense 
of  irregularity  to  the  finger  when  passed  over  the  surface.  They 
increase  in  size,  and  in  the  course  of  forty-eight  hours  assume  a  vesi- 
cular character,  and  contain  a  whey-like  fluid  ;  while,  instead  of  a  coni- 
cal form,  they  now  present  a  central  depression.  During  another  period 
of  forty-eight  hours,  or  thereabouts,  these  vesicles  go  on  enlarging, 
their  central  depression  grows  more  and  more  apparent,  and  their  con- 
tents become  white  and  opaque ;  they  are  no  longer  vesicles,  but  have 
become  converted  into  pustules,  each  of  which,  if  they  be  distinct,  has 
an  areola  of  a  red  hue  around  its  base.  As  the  pustules  enlarge,  the 
face,  hands,  and  feet  become  swollen,  and  a  general  redness  of  the 
surface  succeeds  to  the  more  circumscribed  areola  which  had  previously 
surrounded  each  separate  pustule.  As  the  size  of  the  pustules  increases, 
they  lose  that  central  depression  which  they  had  presented  while  vesi- 
cles ;  they  assume  a  spheroidal  form,  or  even  become  slightly  conical. 
The  next  change  observable  in  them  is  an  alteration  of  their  color  from 
a  white  to  a  dirty  yellow  tint,  which  they  continue  to  retain  until  the 
desiccation  of  the  eruption  commences.  This  token  of  the  decline  of 
the  disease  is  first  apparent  on  the  face,  where,  as  you  will  remember, 
the  eruption  is  earliest  observable  ;  while  on  the  hands  and  feet,  pro- 
bably owing  to  the  thickness  of  the  epidermis  in  those  situations,  this 
change  is  longest  delayed,  and  the  pustules  there  attain  a  greater  size 
than  in  any  other  situation.  The  maturation  of  the  pustules  usually 
occupies  from  the  commencement  of  the  fifth  to  the  commencement  of 
the  eighth  day  of  the  eruption,  or  from  the  eighth  to  the  eleventh  day 
of  the  disease  ;  when  the  process  of  desiccation  begins.  A  few  of 
the  smaller  pustules  dry  up  and  become  converted  into  crusts,  which 
afterwards  drop  off ;  but  the  greater  number  of  them  burst,  and  the 
pus  which  they  discharge,  together  with  a  very  adhesive  matter  which 
they  continue  to  secrete  for  two  or  three  days  contribute  to  form  the 
scab,  which  incrusts,  more  or  less  extensively,  the  surface  of  a  small- 
pox patient  during  the  decline  of  the  disease.  When  this  scab  falls  off, 
which  it  does  in  from  three  to  five  or  six  days,  the  skin  appears  stained 
of  a  reddish-brown  colour,  which  often  does  not  disappear  for  several 
weeks  ;  but  it  is  only  in  cases  where  the  pustule  has  gone  so  deep  as  to 
destroy  a  portion  of  the  true  skin,  that  permanent  disfigurement,  the 
so-called  pitting  of  the  small-pox,  is  produced. 

It  is  only  in  cases  of  discrete  small-pox,  in  which  the  eruption  is  but 


458  PROGRESS   OF    THE   ERUPTIONS. 

moderately  abundant,  and  the  pustules  consequently  run  their  course 
"without  coalescing  with  each  other,  that  the  above-mentioned  changes 
can  be  distinctly  traced.  In  the  confluent  variety  of  the  disease,  in 
which  the  pustules  are  so  numerous  that  they  run  together  as  they 
increase  in  size,  the  characteristic  alterations  in  the  individual  pustules 
cannot  be  followed.  In  those  situations  where  the  eruption  is  confluent, 
the  pustules  never  attain  the  size  which  separate  pustules  often  reach ; 
they  do  not  become  so  prominent,  nor  do  their  contents  in  general 
assume  the  same  yellowish  colour,  but  several  of  them  coalesce  to  form 
a  slightly  irregular  surface  of  a  whitish  hue ;  while,  when  the  stage  of 
desiccation  comes  on.,  each  of  these  patches  becomes  converted  into  a 
moist  brown  scab,  which  is  many  days  before  it  is  detached.  Nor  is  it 
merely  at  those  parts,  such  as  the  face,  where  the  eruption  is  actually 
confluent,  that  its  character  is  modified,  but,  even  where  the  pustules 
are  distinct,  their  advance  goes  on  more  slowly,  and  the  maturative 
stage  is  longer  in  being  completed,  than  in  less  severe  cases  of  the 
disease.  It  is,  moreover,  in  cases  of  confluent  small-pox  that  the  ulce- 
ration of  the  pustules  most  commonly  invades  the  true  skin,  and  that 
serious  disfigurement  is  most  likely  to  take  place ;  while  further,  the 
degree  of  danger  to  life  is  in  almost  direct  proportion,  in  every  case  of 
small-pox,  to  the  amount  of  confluence  of  the  eruption. 

The  appearance  of  the  eruption  of  small-pox  is  attended  with  a  great 
abatement,  sometimes  with  the  almost  complete  disappearance,  of  those 
signs  of  constitutional  disturbance  with  which  the  disease  set  in  ;  and  in 
mild  cases  the  child  shews  few  other  signs  of  illness  than  are  furnished 
by  the  eruption  on  the  skin.  But,  with  the  maturation  of  the  pustules, 
the  secondary  fever,  as  it  is  called,  is  excited,  and  the  period  of  the 
greatest  danger  to  the  patient  now  comes  on.  The  skin  once  more 
grows  hot ;  the  pulse  rises  in  frequency ;  restlessness,  thirst,  and  all  the 
phenomena  of  inflammatory  fever,  develope  themselves,  and  continue 
with  more  or  less  intensity  for  about  three  days.  These  symptoms 
afterwards  diminish,  and  finally  disappear  as  the  pustules  burst,  and  the 
stage  of  desiccation  is  accomplished.  It  is,  however,  only  in  cases  of  a 
favourable  kind  that  the  secondary  fever  runs  so  mild  a  course.  In 
confluent  small-pox,  the  secondary  fever  is  always  more  severe  than  in 
the  discrete  form  of  the  disease,  though  it  comes  on  later,  in  consequence 
of  the  more  tardy  maturation  of  the  pustules.  Often,  indeed,  it  assumes 
a  typhoid  character ;  the  pulse  becomes  extremely  frequent  and  feeble ; 
the  tongue  dry  and  brown ;  and  the  patient  lies  delirious.  In  other 
instances  the  maturation  of  the  pustules  goes  on  for  a  day  or  two  with 
very  slight  reaction ;  and  were  it  not  that  this  extreme  mildness  of  the 
secondary  fever,  in  cases  where  the  eruption  has  been  abundant,  is  itself 
a  suspicious  circumstance,  we  should  be  disposed  to  express,  without 
hesitation,  a  most  favourable  opinion  as  to  the  patient's  condition. 
Suddenly,  however,  the  pulse  begins  to  falter;  the  pustules,  which 
before  seemed  full,  collapse ;  the  extremities  grow  cold ;  and  in  a  few 
hours  the  patient  dies.  This  fatal  change  is  sometimes  ushered  in  by  a 
fit  of  convulsions ;  at  other  times  it  is  preceded  by  a  condition  of  extreme 
restlessness,  which  contrasts  remarkably  with  the  quietude  of  the  child's 
manner  for  the  two  or  three  previous  days ;  and  it  is  well  to  bear  in 


DANGERS   ATTENDING   THE   MATURATIVE   STAGE.  459 

mind  that  the  supervention  of  either  of  these  two  symptoms  during  the 
maturative  stage  of  small-pox  is  the  almost  certain  herald  of  speedily 
approaching  death.  One  other  not  infrequent  source  of  danger  during 
this  period  arises  from  the  pustules  which  have  formed  on  the  mucous 
membrane  of  the  mouth,  fauces,  and  air-passages.  In  almost  every  case 
of  small-pox,  a  few  spots  of  the  eruption  may  be  seen  upon  the  tongue 
and  on  the  interior  of  the  mouth ;  while  an  inspection  of  the  bodies  of 
patients  to  whom  it  has  proved  fatal  has  shown  that  the  pustules  form 
likewise  on  the  interior  of  the  larynx  and  trachea — sometimes  in  consi- 
derable numbers.  It  is  to  the  presence  of  pustules  in  theses  situations 
that  the  hoarse  or  altered  voice,  and  the  difficulty  of  deglutition,  which 
are  observed  in  most  cases  of  severe  small-pox,  are  due ;  as  well  as  that 
short  hacking  cough  which  sometimes  proves  a  very  troublesome  symp- 
tom. The  ptyalism,  too,  which  occurs  in  many  instances,  is  apparently 
owing  to  the  salivary  glands  sympathising  with  the  irritated  and 
inflamed  state  of  the  mucous  membrane  of  the  mouth.  In  cases  which 
run  a  fortunate  course,  these  symptoms,  having  come  on  about  the  third 
or  fourth  day  of  the  eruption,  and  having  increased  in  severity  until  the 
eighth  or  ninth,  then  progressively  decline.  Under  less  favourable  cir- 
cumstances, however,  they  continue  to  grow  worse :  the  voice  becomes 
perfectly  extinct,  and  deglutition  almost  impossible ;  and  the  patient 
dies  from  the  obstacle  which  the  inflammation  and  swelling  of  the  lining 
membrane  of  the  larynx  present  to  the  free  access  of  air  to  the  lungs ; 
though  the  symptoms  are  seldom  or  never  those  of  active  inflammatory 
croup. 

You  will  fimi  in  the  writings  of  those  whose  opportunities  of  observing 
small-pox  have\been  considerable,  the  description  of  many  other  modes 
in  which  it  occasionally  proves  fatal.  Thus,  it  is  sometimes  associated 
with  a  great  tendency  to  haemorrhage ;  petechia  appearing  on  the  sur- 
face of  the  body,  and  the  pustules  assuming  a  black  colour,  from  the 
extravasation  of  blood  into  them.  In  other  instances,  gangrene  attacks 
the  feet  or  some  other  part  of  the  body.  But  these  are  occurrences 
which  it  has  not  been  my  lot  to  witness,  and  I  will  not  therefore  take 
up  your  time  by  detailing  them  at  second-hand. 

Let  us  now  glance  for  a  few  minutes  at  the  treatment  to  be  pursued 
in  this  disease.  You  know  that  before  the  time  of  Sydenham,  physicians 
adopted  a  heating  regimen  in  cases  of  small-pox;  excluding  fresh  air 
from  the  chamber,  covering  the  patient  with  blankets,  and  administering 
stimulating  medicines  and  cordial  drinks.  To  this  practice  the  preva- 
lent theory  of  fermentation,  and  of  nature's  efforts  in  disease  being 
directed  to  eliminate  the  peccant  matter  from  the  blood,  had  given  occa- 
sion. In  accordance  with  these  notions  it  was  assumed  that  the  more 
abundant  the  eruption,  the  more  complete  would  be  the  separation  of 
these  noxious  matters,  and  consequently  the  better  the  chance  of  the 
patient's  well-doing.  The  observation  of  nature,  however,  taught  Syden- 
ham that  the  very  reverse  was  the  case ; — that  the  more  abundant  the 
eruption,  the  greater  the  danger, — the  fewer  the  pustules,  the  more 
favourable  the  prospect  of  the  patient's  recovery.  A  cooling  regimen, 
therefore,  is  now  universally  adopted  in  the  early  stage  of  the  disease, 
and  fresh  air  is  freely  admitted  into  the  chamber,  in  order  to  prevent, 


4G0  TREATMENT    OF   SMALL-POX. 

if  possible,  a  copious  eruption,  while  the  same  end  is  sought  to  be  still 
further  promoted  by  keeping  the  bowels  gently  open,  by  a  spare  diet, 
and  by  mild  antiphlogistic  medicines.  Depletion,  which  even  in  the 
adult  is  not  to  be  practised  merely  with  the  hope  of  thereby  diminishing 
the  quantity  of  the  eruption,  is  still  less  to  be  resorted  to  in  the  child, 
unless  evidently  called  for  by  symptoms  of  severe  cerebral  disturbance ; 
such  as  convulsions  frequently  recurring,  or  ending  in  coma.  Such' 
occurrences  as  those,  however,  demand  not  merely  the  abstraction  of 
blood,  but  its  removal  with  an  unsparing  hand ;  for,  as  I  told  you  at 
the  commencement  of  these  lectures,  the  cerebral  congestion  which 
attends  the  onset  of  the  eruptive  fevers,  if  not  speedily  relieved,  may 
prove  very  quickly  fatal.  Cases  of  an  opposite  kind  are  sometimes  met 
with  in  wThich  the  patient  before  the  appearance  of  the  eruption  is  in  a 
state  of  depression  so  great  as  to  call  for  warmth  to  the  surface,  or  for 
the  hot  bath,  for  diaphoretic  medicines,  and  sometimes  even  for  stimu- 
lants. In  this,  however,  there  is  nothing  more  than  we  may  occasionally 
witness  in  a  patient  completely  prostrated  during  the  first  stage  of 
typhus  fever,  and  needing  perhaps  the  free  administration  of  wine  and 
ammonia  to  preserve  him  from  death. 

With  the  outbreak  of  the  eruption  there  ensues  a  lull  in  the  symp- 
toms, and  a  period  now  succeeds  during  which  we  have  nothing  else  to 
do  than  to  leave  nature  to  her  workings  undisturbed.  Even  in  cases  of 
confluent  small-pox,  there  is  in  many  instances  not  a  single  symptom 
just  at  this  time  which  could  either  excite  solicitude  or  call  for  treatment, 
and  you  must  therefore  take  care  not  to  allow  yourself  at  this  moment 
to  be  betrayed  into  the  hasty  expression  of  a  very  favourable  prognosis, 
which  the  supervention  of  the  secondary  fever  may  perhaps  in  a  day  or 
two  most  grievously  belie.  If,  however,  the  number  of  pustules  should 
be  but  small,  the  secondary  fever  will  be  slight:  our  favourable  opinion 
may,  under  these  circumstances,  be  expressed  with  some  confidence, 
and  most  probably  no  deviation  from  our  previous  expectant  plan,  of 
treatment  will  be  required  during  the  subsequent  progress  of  the 
disease.  If  the  eruption  be  more  abundant,  and  the  accompanying 
secondary  fever  consequently  severe,  an  antiphlogistic  plan  of  treatment 
must  be  carried  out  more  strictly,  while  in  all  cases  the  restlessness 
which  is  so  common  a  symptom  during  the  maturative  stage  of  small- 
pox must  be  controlled  by  the  administration  of  Dover's  powder,  or  of 
some  other  form  of  opiate,  once  or  twice  a  day.  In  cases  of  confluent 
small-pox,  the  patient  needs  to  be  very  closely  watched  during  the 
maturation  of  the  pustules,  for  on  the  second  or  third  day  of  this 
process  the  vital  powers  sometimes  suddenly  fail.  The  first  indications 
of  any  such  occurrence,  which  would  be  furnished  by  a  great  aggrava- 
tion of  the  previous  restlessness,  by  the  subsidence  of  the  swelling  of 
the  face  and  hands,  the  paleness  of  the  skin  in  the  interval  between  the 
pustules,  and  the  collapse  of  the  pustules  themselves,  attended  with  a 
sinking  in  the  temperature  of  the  surface,  and  a  great  diminution  in  the 
power  of  the  pulse,  call  at  once  for  the  energetic  employment  of  stimu- 
lants, for  the  administration  of  wine,  and  the  substitution  of  nutritious 
food  for  the  previous  meagre  diet.  A  similar  course  must  also  be 
pursued  whenever  the  secondary  fever  shows  any  disposition  to  assume 


TREATMENT   OF   THE   SECONDARY   FEVER.  461 

a  typhoid  character,  while,  irrespective  of  any  unfavourable  symptoms, 
it  is  not  infrequently  expedient,  if  the  eruption  be  abundant,  to  give 
beef-tea,  and  to  adopt  other  means  for  supporting  the  strength  from 
the  fifth  or  sixth  day  of  the  eruption — a  period  corresponding,  as  I 
hardly  need  remind  you,  with  the  eighth  or  ninth  day  of  the  disease. 

Various  local  means  have  been  recommended  to  be  adopted  at  an 
early  stage  of  the  disease,  with  the  view  of  preventing  the  full  develop- 
ment of  the  pustules,  and  consequently  of  preserving  the  patient  from 
the  disfigurement  produced  by  the  pitting  of  the  eruption.  The 
cauterization  of  each  individual  pock  with  the  nitrate  of  silver  is  a 
process  impracticable  from  its  tediousness,  while  there  is  some  discrep- 
ancy in  the  results  which  different  persons  allege  that  they  have  obtained 
by  applying  mercurial  ointment  or  plaster,  or  by  washing  the  surface 
which  it  is  wished  to  defend  with  a  solution  of  corrosive  sublimate. 
The  weight  of  evidence  appears  to  me,  however,  to  be  in  favour  of 
some  proceeding  of  this  kind;  and  that  which  seems  to  have  been  the 
most  successful,  is  the  application  of  the  mercurial  plaster  at  a  period 
not  later  than  the  third  day  from  the  outbreak  of  the  eruption. 

Attention  must  be  paid  to  the  state  of  the  eyes,  which  often  suffer  . 
much  during  attacks  of  the  small-pox,  though  Dr.  Gregory  states  that 
the  conjunctiva  never  becomes  the  seat  of  the  pustules.  From  the  time 
when  the  swelling  of  the  face  begins,  during  the  maturation  of  the 
eruption,  the  eyelids  are  often  so  much  swollen  as  completely  to  close 
the  eyes,  while  their  edges  are  glued  together  by  a  tenacious  secretion 
from  the  Meibomian  glands.  The  patient  will  be  much  relieved  by 
bathing  the  Vyes  frequently  with  warm  water,  and  any  pustules  that 
occupy  the  margins  of  the  palpebrse  should  be  carefully  cauterized  with 
the  nitrate  of  silver. 

The  condition  of  the  mouth  and  throat  must  not  be  neglected.  If 
old  enough,  the  child  may  be  made  to  gargle  with  a  little  infusion  of 
roses,  while,  should  it  be  too  young  to  do  this,  the  endeavour  must  be 
made  to  keep  the  mouth  and  throat  free  from  the  secretions  which 
collect  there,  by  washing  or  syringing  them  frequently  with  warm  water, 
and  by  applying  a  weak  solution  of  chloride  of  lime  to  the  fauces.  If 
difficult  respiration  should  come  on,  in  consequence  of  the  affection 
seriously  involving  the  larynx  and  trachea,  the  patient's  condition, 
according  to  the  testimony  of  almost  all  writers,  is  rendered  nearly 
hopeless. 

The  intense  itching  of  the  eruption  during  the  latter  part  of  the 
period  of  maturation,  and  the  stage  of  desiccation,  not  only  distresses 
the  patient  exceedingly,  but  is  often  the  occasion  of  subsequent  dis- 
figurement, in  consequence  of  the  desire  to  scratch  being  irresistible, 
and  the  pustules  being  converted  by  abrasion  of  their  heads  into 
troublesome  ulcerations.  The  application  of  sweet  oil,  cold  cream,  or 
spermaceti  ointment,  will  do  something  towards  allaying  the  irritation ; 
but  you  will  often  find  it  necessary  to  muffle  the  hands  of  children,  in 
order  to  prevent  their  producing  troublesome  sores  by  scratching 
themselves. 

The  convalescence  from  small-pox  is  often  very  tedious ;  the  patient's 
recovery  is  frequently  interrupted  by  various  intercurrent  affections, 


462  SMALL-POX   AFTER   VACCINATION. 

and  the  latent  seeds  of  scrofulous  disorder  are  in  many  instances  called 
into  activity  by  its  attack.  These,  however,  are  occurrences  which 
present  nothing  of  a  special  character,  and  it  is  therefore  unnecessary 
to  make  any  observation  with  reference  to  their  treatment. 

Although  previous  vaccination  usually  confers  upon  the  system  a 
complete  immunity  from  subsequent  attacks  of  small-pox,  yet  to  this 
rule  there  are  occasional  exceptions.  In  many  instances,  indeed,  the 
occurrence  of  small-pox  after  alleged  successful  vaccination  may  be 
accounted  for  by  the  careless  performance  of  that  operation,  by  the  use 
of  lymph  taken  from  the  arm  at  too  late  a  period,  or  by  the  production 
in  some  way  of  a  spurious  instead  of  a  genuine  vaccine  vesicle.  It 
must  be  confessed,  however,  that  when  every  allowance  has  been  made 
for  these  casualties,  the  number  of  cases  of  small-pox  occurring  after 
successful  vaccination  is  proportionably  much  greater  than  the  number 
in  which  a  second  attack  of  small-pox  is  experienced  by  those  who 
have  either  had, that  disease  casually,  or  in  whom  it  has  been  produced 
by^  variolous  inoculation.  It  would  occupy  far  more  time  than  we  have 
at  our  command,  if  we  were  to  attempt  to  enter  upon  the  inquiry  as 
to  the  causes  of  the  failure  in  the  protective  power  of  vaccination. 
Different  views  have  been  taken  by  very  high  authorities  upon  this 
subject ;  but  there  is  one  important  fact  concerning  which  nearly  all 
are  agreed — namely,  that  the  liability  to  a  subsequent  attack  of  small- 
pox is  almost  incalculably  diminished  by  revaccination.  Considering, 
then,  how  simple  the  operation  is,  and  how  nearly  painless  its  perform- 
ance, while  the  benefit  to  be  obtained  by  it  is  so  inestimable,  I  would 
strongly  urge  you  to  revaccinate  all  persons  turned  twelve  years  old, 
even  though  they  had  been  vaccinated  with  the  most  complete  success 
in  their  infancy.1 

But  although  we  should  take  a  comparatively  low  estimate  of  the 
value  of  vaccination,  and  confess  to  the  fullest  extent  the  failure  in 
its  complete  preservative  virtue,  we  shall  yet  find,  in  the  modifying 
and  mitigating  influence  which  it  exerts  over  small-pox,  more  than 
enough  to  make  us  value  it  as  a  priceless  boon.  Twenty  years  ago, 
small-pox  raged  epidemically  at  Marseilles,  where  it  attacked  almost 
exclusively  persons  under  30  years  of  age.  M.  Favart,3  who  sent  an 
account  of  this  epidemic  to  the  Academy  of  Medicine  at  Marseilles, 
estimated  the  number  of  the  inhabitants  of  that  city  under  30  years 
of  age  at  40,000.  Of  these,  about  30,000  had  been  vaccinated,  2,000 
had  had  small-pox  casually  or  by  inoculation,  and  8,000  had  had 
neither  variola  nor  cow-pox.  Of  this  last  class,  4,000,  or  1  in  2,  were 
attacked  by  small-pox,  and  1,000  of  them,  or  1  in  4,  died.  Of  those 
who  had  had  small-pox  previously,  only  20,  or  1  in  1,000,  were  again 
affected ;  but  4  of  these,  or  1  in  5,  died ;  while  of  the  vaccinated, 
although  2,000,  or  1  in  15,  had  it,  yet  it  proved  fatal  only  to  20,  or  1 
per  cent. 

The  influence  of  vaccination  in  rendering  attacks  of  small-pox  which 
may  succeed  to  it,  so  much  less  severe,  and  so  much  less  dangerous, 

1  For  facts  shewing  the  preservative  influence  of  re-vaccination,  see  Steinbrenner, 
Trnit6  sur  la  Vaccine,  8vo.  pp.  688-734.     Paris,  1846. 

2  As  reported  by  Steinbrenner,  op.  cit.  p.  166. 


CHICKEN-POX.  463 

than  the  unmodified  disease,  does  not  in  many  instances  manifest  itself 
in  any  diminution  of  the  intensity  of  the  primary  fever.  The  symp- 
toms with  w  hih  modified  small-pox  sets  in  are  often  as  severe  as  those 
of  the  unmodified  disease,  and  are  also  in  general  of  the  same  duration. 
So  soon  as  the  eruption  begins  to  make  its  appearance,  however,  the 
difference  between  the  two  diseases  usually  becomes  apparent.  In  many 
instances,  notwithstanding  the  sharp  onset  of  the  patient's  illness,  the 
eruption  is  exceedingly  scanty,  not  more  than  from  twenty  to  a  hundred 
pustules  appearing  over  the  whole  body.  In  other  instances,  the  erup- 
tion is  much  more  abundant,  and  in  a  few  exceptional  cases  the  pustules 
are  actually  confluent.  But  even  when  they  are  most  numerous,  the 
postules  seldom  fail  to  follow  a  different  course  from  that  which  they 
pursue  inordinary  variola,  and  run  through  their  different  stages  within 
little  more  than  half  the  period  required  by  the  eruption  of  unmodified 
small-pox.  The  small  size  of  the  pocks, — the  frequent  absence  of  the 
central  depression, — their  imperfect  suppuration, — and  their  speedy 
desiccation,  are  the  chief  local  characters  of  this  affection  ;  while  the 
almost  complete  absence  of  the  secondary  fever  is  both  its  grand  con- 
stitutional peculiarity  and  the  main  source  of  the  patient's  safety. 

Besides  the  modified  small-pox  to  which  reference  has  just  been  made, 
there  is  another  and  still  milder  affection  often  observed  in  children,  to 
which,  from  the  extreme  lightness  of  the  symptoms  that  usually  attend 
it,  the  diminutive  appellation  of  varicella  or  chicken-pox  has  been  given. 
Much  difference  of  opinion  has  existed  with  reference  to  the  relations 
bornby  this  disease  to  small-pox;  and  even  at  the  present  day  writers 
are  not  quite  agreed  whether  to  regard  it  as  an  extremely  mild  form  of 
variola,  or  as\an  affection  altogether  distinct  from  it.  The  weight  of 
evidence,  however,  is  decidedly  in  favour  of  the  opinion  that  varicella  is 
an  affection  distinct  from,  and  wholly  independent  of  small-pox,  not 
being  produced  by  any  modification  of  the  poison  of  that  disorder,  nor 
affording  any  kind  of  protection  from  its  attacks. 

Varicella  is  almost  exclusively  a  disease  of  childhood,  and  in  the 
great  majority  of  cases  it  occurs  prior  to  the  completion  of  the  first 
dentition.  Its  initiatory  fever,  which  is  scarcely  ever  severe,  is  some- 
times altogether  wanting,  so  that  the  appearance  of  the  eruption  on 
the  surface  is  the  first  occurrence  that  calls  attention  to  the  child's  con- 
dition. Now  and  then,  however,  exceptions  occur  to  this  mildness  in 
the  onset  of  the  disease ;  and  I  have  occasionally  seen  children 
(chiefly  those  in  whom  the  process  of  dentition  was  going  on  with 
activity  at  the  time  of  the  attack)  suffer  for  twenty-four  or  thirty-six 
hours  from  febrile  symptoms  quite  as  severe  as  those  which  precede  the 
attack  of  measles,  or  as  accompany  a  sharp  attack  of  influenza.  The 
duration  of  this  premonitory  stage  of  chicken-pox  is  somewhat  uncer- 
tain ;  the  vesicles  which  characterize  it  making  their  appearance  after 
twenty-four  hours  in  some  cases, — not  for  thirty-six  or  forty-eight  hours 
in  others ;  while,  as  already  mentioned,  the  eruption  is  occasionally  the 
first  symptom  of  the  existence  of  the  disease. 

The  eruption  usually  consists  of  more  or  less  numerous,  minute, 
circular  vesicles,  containing  a  transparent  serum,  irregularly  distributed 
over  the  face,  head,  shoulders,  and  trunk,  but  rarely  appearing  on  the 


464  MEASLES. 

lower  extremities  ;  and,  even. when  present  in  considerable  abundance, 
being  very  seldom  confluent  at  any  part.  For  two  or  three  days  they 
increase  somewhat  in  size,  but  their  contents  then  become  turbid  and 
milky ;  about  the  fourth  or  fifth  day  they  shrivel,  and  then  dry  up  into 
a  light,  pulverulent  scab,  which  falls  off  on  the  eighth  or  ninth  day  of 
the  disease.  It  very  seldom  happens  that  any  cicatrix  is  left  after  the 
detachment  of  the  scab  of  varicella,  unless  the  skin  has  been  irritated  by 
the  patient  scratching  it  in  order  to  relieve  the  itching,  which  is  some- 
times very  troublesome.  Besides  these  differences  between  the  eruption 
of  chicken-pox  and  that  of  variola,  another,  and  still  more  striking 
peculiarity  of  the  former  disease  consists  in  the  appearance  of  two  or 
three  successive  crops  of  vesicles,  so  that  after  the  third  day  of  the 
affection  vesicles  may  be  observed  close  to  each  other  in  all  stages  of 
their  progress. 

The  disease  is  one  so  void  of  danger,  that  it  requires  hardly  any 
treatment  beyond  the  adoption  of  a  mild  antiphlogistic  regimen ;  and 
no  complications  occur  during  its  course,  nor  sequelas  remain  after  its 
.  disappearance,  concerning  which  any  thing  more  need  be  added. 


LECTUEE    XXXIX. 


Measles — once  confounded  with  scarlatina,  though  essentially  different  diseases.  — 
Symptoms  of  measles — their  chief  danger  due  to  the  supervention  of  bronchitis  or 
pneumonia. — Treatment. 

Scarlatina — great  differences  in  its  severity  in  different  cases — symptoms  of  each  of 
its  three  varieties— sequelse  of  the  disease — diagnosis  from  measles. — Treatment. 

When  the  short-lived  prejudices  which  at  first  were  entertained 
against  vaccination  had  been  removed,  men  passed,  as  they  not  seldom 
do,  to  the  opposite  extreme,  and  over-estimated  the  worth  of  that 
discovery  which  they  had  before  undervalued.  Physicians  rejoiced  in 
it,  as  a  means  of  getting  rid  for  ever  of  a  disease  which  might  well  be 
counted  among  the  opprobria  of  their  art, — philanthropists  exulted  in 
the  probable  extermination  of  one  of  the  most  fearful  scourges  of  the 
human  race,  and  statisticians  counted  the  increase  brought  to  the 
population,  and  drew  up  elaborate  tables  to  illustrate  their  bright 
anticipations  of  the  future.1  In  these  over-sanguine  calculations,  how- 
ever, they  almost  entirely  lost  sight  of  the  fact,  that  not  all  who  were 
preserved  from  small-pox  would  be  added  to  the  useful  population  of 
the  country,  but  that  the  life  of  many  would  be  prolonged  only  for  a 
short  season,  to  be  cut  off  soon  by  some  other  disease,  against  which 
neither  science  nor  fortunate  accident  has  hitherto  discovered  a  talis- 
man. Experience  has  proved  the  truth  of  what  calm  reflection  might 
have  suggested,  and  with  the  diminution  in  the  frequency  of  small-pox 
there  has  been  an  increase,  though  not  to  an  equal  extent,  in  the 
prevalence  of  measles  and  scarlatina. 

It  is  not  easy  to  state  with  exactness  the  amount  of  mortality  which 
these  two  diseases  occasion,  for  though  they  are  never  altogether  absent 

1  As  an  instance  of  which  may  be  mentioned  the  work  of  Duvillard,  De  l'lnfluence  de 
la  petite  verole  sur  la  Mortalite,  4to.     Paris,  i806. 


MEASLES   AND   SCARLET   FEVER   NOT   THE    SAME   DISEASE.  465 

from  a  large  city  like  London,  yet  their  frequency  and  their  fatality 
vary  much  in  different  years.  At  one  time  they  occur  sporadically, 
and  are  then  in  most  instances  mild  in  their  character,  and  readily 
amenable  to  treatment ;  while  at  another  time  they  prevail  as  epidemics, 
and  are  attended  with  alarming  symptoms,  which  it  is  often  not  in  the 
power  of  medicine  to  control.  Dr.  Gregory,  who,  in  his  work  on  the 
Eruptive  Fevers,  has  collected  together  with  much  labour  the  statistics 
of  these  diseases,  presents  us  with  a  table,  from  which  it  appears  that, 
on  an  average  of  five  years,  very  nearly  six  per  cent,  of  the  mortality 
of  London  is  due  to  measles  and  scarlatina.  This  number,  indeed,  is 
not  so  great  as  at  once  to  impress  us  with  the  formidable  nature  of 
these  two  affections ;  but  it  should  not  be  forgotten,  that  (according  to 
the  Fifth  Report  of  the  Register-General),  81  per  cent,  of  this  mortality 
occurs  in  children  under  five  ;  and  97  per  cent,  in  children  under  ten 
years  old ;  while  no  figures  can  accurately  represent  the  instances  in 
which  death  is  occasioned  by  their  complications  or  sequelae. 

These  two  diseases  present  many  points  of  resemblance, — so  many, 
indeed,  that  they  were  long  supposed  to  be  but  varieties  of  the  same 
malady ;  and  the  essential  differences  between  them  were  not  recog- 
nized till  within  the  last  seventy  years.  It  is,  however,  on  many 
accounts  important  to  distinguish  between  them, — for  not  only  are  they 
not  attended  by  the  same  degree  of  danger,  but  this  danger  arising 
from  dissimilar  causes,  the  treatment  which  they  require  is  in  many 
respects  different.  We  shall  presently  examine  into  some  of  those 
peculiarities  in  their  symptoms  on  which  we  chiefly  rely  in  forming  our 
diagnosis  beWeen  the  two  affections,  but  I  may  even  now  state  some  of 
the  broad  distinctions  between  them. 

Measles  is  still  more  eminently  than  scarlet  fever  a  disease  of  early 
childhood, — for  of  1298  deaths  which  it  occasioned  in  London  in  1842, 
93-8  per  cent,  occurred  in  children  under  five  years  old,  and  99  per 
cent,  in  those  under  the  age  of  ten  ;  while  of  1224  deaths  from  scar- 
latina 31  per  cent,  occurred  after  five,  and  10  per  cent,  after  ten  years 
of  age.  Though  there  are  great  fluctuations  both  in  its  prevalence  and 
in  the  mortality  which  it  occasions,  yet  its  variations  in  these  respects 
are  less  considerable  than  those  of  scarlet  fever ;  while  the  number  of 
persons  who  pass  through  life  without  having  experienced  its  attack  is 
smaller  than  of  those  who  die  without  ever  having  been  affected  with 
scarlatina.  Though  a  more  universally  prevalent  disease,  however,  it 
is  fortunately  less  dangerous,  its  mortality  not  exceeding  3  per  cent, 
of  the  patients  attacked  by  it ;  while  the  medium  rate  of  mortality 
from  scarlet  fever  is  estimated  as  at  least  double  that  amount.  When 
measles  proves  fatal,  too,  it  is  very  seldom  the  fever  itself  which  occa- 
sions the  patient's  death,  but  generally  its  complication  with  inflam- 
matory disease  of  the  respiratory  organs.  Scarlet  fever,  on  the  con- 
trary, destroys  its  victims  in  all  stages  of  the  disease :  and  in  many  of 
the  worst  cases,  in  which  death  takes  place  early,  no  organic  change  is 
left  behind  which  the  scrutiny  of  the  anatomist  can  discover. 

The  symptoms  that  attend  the  onset  of  measles  present  little  besides 
their  greater  severity  to  distinguish  them  from  those  of  ordinary  catarrh. 
A  child  previously  in  perfect  health,  becomes  suddenly  restless,  thirsty, 

30 


466  SYMPTOMS   OP  MEASLES. 

and  feverish,  and,  if  able  to  talk,  generally  complains  of  head-ache. 
The  eyes  grow  red,  weak  and  wattery,  and  are  unable  to  bear  the 
light ;  the  child  sneezes  very  frequently,  sometimes  almost  every  five 
minutes,  and  is  troubled  by  a  constant,  short,  dry  cough.  On  the  fourth 
day  from  the  commencement  of  these  symptoms,  a  rash  makes  its  ap- 
pearance on  the  face,  whence  it  extends  in  the  course  of  about  forty- 
eight  hours  to  the  rest  of  the  body  and  the  extremities,  travelling  in  a 
direction  from  above  downwards.  The  rash  is  made  up  of  a  number  of 
minute,  deep  red,  circular  stigmata,  not  unlike  flea-bites,  slightly 
elevated,  especially  on  the  face,  and  though  close  together,  yet  usually 
distinct  from  each  other  ;  the  skin  in  the  interspaces  between  them 
retaining  its  natural  colour.  On  the  cheeks,  the  spots  sometimes  become 
confluent,  and  then  form  irregular  blo:ches,  about  a  third  of  an  inch 
long  by  half  that  breadth ;  while  the  spots  elsewhere  often  present  an 
indistinctly  crescentic  arrangement.  The  eruption  fades  in  the  same 
order  as  that  in  which  it  appeared,  and  after  the  lapse  of  forty-eight 
hours  from  its  appearance,  at  which  time  it  is  at  its  height  on  the  trunk, 
it  is  beginning  to  disappear  from  the  face.  On  the  seventh  day  of  the 
disease  the  rash  grows  faint  on  the  body  generally,  and  on  the  eighth, 
or  at  latest  the  ninth  day,  it  has  entirely  vanished,  leaving  behind  either 
a  little  general  redness  of  the  surface,  or  a  few  yellowish  red  spots, 
corresponding  to  some  of  the  situations  which  the  eruption  itself  had 
occupied.  In  some  cases  a  partial  desquamation  of  the  cuticle  takes 
place  after  the  rash  has  disappeared  ;  but  this  is  by  no  means  constant, 
while,  when  it  occurs,  the  epidermis  separates  in  minute  branny  scales, 
never  in  large  portions,  as  it  often  does  after  scarlatina. 

Unlike  small-pox,  in  which  the  appearance  of  the  eruption  is  imme- 
diately followed  by  the  subsidence  of  all  the  previous  symptoms,  the 
constitutional  disturbance  of  measles  is  in  many  instances  not  at  all 
alleviated  on  the  outbreak  of  the  rash.  The  reverse,  indeed,  is  fre- 
quently the  case  ;  and  in  many  instances,  for  twenty-four  or  forty- eight 
hours  afterwards,  the  fever  is  aggravated,  and  the  cough  more  trouble- 
some than  before,  while  the  voice  often  becomes  hoarser,  and  the  throat 
is  somewhat  sore  in  consequence  of  the  inflammation  of  the  palate  and 
fauces,  which  may  be  seen  to  be  the  seat  of  a  punctated  redness,  re- 
sembling that  produced  by  the  eruption  on  the  skin. 

The  aggravation  of  the  symptoms,  however,  when  it  does  occur,  is 
only  temporary ;  and  on  the  sixth  day  of  the  disease,  if  not  sooner,  an 
amelioration  in  the  patient's  condition  becomes  apparent;  the  fever 
diminishing,  the  cough  growing  looser  and  less  frequent,  and  moist 
sounds  becoming  audible  in  the  lungs,  where  previously  nothing  was 
heard  but  rhonchus  or  sibilus.  In  cases,  however,  in  which  the  disease 
takes  a  less  favourable  turn,  this  is  the  period  when  the  supervention  of 
serious  thoracic  complication  is  most  to  be  feared*  It  happens,  indeed, 
occasionally,  that  the  disorder  of  the  respiratory  organs  is  severe  from 
the  very  commencement  of  the  child's  illness,  and  that  it  merely  becomes 
aggravated  with  the  progress  of  the  disease.  But  in  the  majority  of 
cases,  it  is  not  until  the  eruption  has  already  reached  its  acme,  or  is 
just  beginning  to  fade,  that  serious  inflammation  of  the  larynx  or 
bronchi,  or  of  the  substance  of  the  lungs,  is  set  up,  while  the  symptoms 
of  any  such  occurrence  need  to  be  watched  all  the  more  carefully  at 


COMPLICATIONS    OF   MEASLES.  467 

this  period,  from  the  rapidity  with  which  they  tend  to  a  fatal  issue. 
Still  although  the  danger  from  mischief  in  the  chest  is  most  imminent 
at  this  stage  of  the  disease,  yet  the  same  symptoms  may  come  on  at  a 
later  period,  when  the  eruption  has  already  faded  for  one  or  two  days  ; 
or  even  later,  and  at  a  time  when  a  sort  of  incomplete  convalescence  is 
already  established.  I  need  not  now  do  more  than  remind  you  of  the 
croupal  symptoms  which  sometimes  come  on  at  the  decline  of  measles, 
and  which,  as  I  mentioned  some  days  ago,1  are  so  dangerous  and  intract- 
able. At  this  period,  too,  inflammation  of  the  substance  of  the  lungs  is 
to  be  dreaded,  and  all  the  more  from  its  coming  on  almost  impercep- 
tibly, unattended  with  much  cough  or  dyspnoea,  and  associated  with 
such  considerable  sympathetic  disturbance  of  the  stomach  and  bowels, 
as  very  readily  to  lead  into  error  with  reference  to  the  seat  of  the  dis- 
ease. The  course  of  the  affection  of  the  lungs  in  this  case  is  usually 
chronic;  the  child  loses  flesh, — becomes  the  subject  of  an  irregular 
hectic  fever ;  and  when  the  thoracic  symptoms  at  length  become  more 
apparent  than  at  first  they  had  been,  and  the  cough  grows  more  frequent 
and  attended  with  more  expectoration,  the  case  so  strongly  resembles 
one  of  tubercular  phthisis  that  it  is  exceedingly  difficult  to  avoid  an 
erroneous  diagnosis. 

The  treatment  of  measles  is  usually  very  simple :  in  mild  cases,  in- 
deed, little  is  needed  beyond  confinement  to  a  warm  chamber,  a  spare 
diet,  and  gentle  antiphlogistic  remedies.  The  cuugh,  which  is  the  most 
troublesome  symptom, — frequently,  indeed,  the  only  one  that  calls  for 
much  attention, — is  often  very  much  relieved  by  the  application  for 
three  or  four^ hours,  of  a  small  blister,  no  bigger  than  a  shilling,  to  the 
trachea,  at  the  point  just  above  the  sternum ;  and  this  slight  counter- 
irritation,  which  seldom  produces  any  vesication  of  the  surface,  may  be 
repeated  during  the  course  of  the  affection.  If  more  than  this  be  needed, 
small  doses  of  antimonial  and  ipecacuanha  wine,  with  laudanum  or  the 
compound  tincture  of  camphor,  may  be  given  every  few  hours.  The 
imperfect  desquamation  that  sometimes  takes  place  as  the  eruption 
declines,  is  often  attended  with  very  distressing  itching  of  the  whole 
surface ;  while  the  cough  is  sometimes  frequent  and  troublesome  at 
night,  and  the  child  is  thus  prevented  from  sleeping.  To  relieve  these 
troublesome  symptoms,  as  well  as  to  check  that  tendency  to  diarrhoea 
which  often  comes  on  at  the  decline  of  measles,  it  is  desirable  to  follow 
the  plan  pursued  by  Sydenham,  and  to  give  an  opiate  every  night, — a 
small  dose  of  Dover's  powder  being  the  best  form  in  which  it  can  be 
administered. 

But  though  these  simple  measures  are  amply  sufficient  in  the  great 
majority  of  cases,  we  yet  must  not  allow  ourselves  to  be  betrayed  into 
inertness  when  any  indications  of  mischief  in  the  chest  make  their 
appearance.  Such  symptoms  sometimes  come  on  early  in  the  disease, 
and  before  the  eruption  has  well  appeared,  the  child  seeming  much 
oppressed,  and  experiencing  considerable  dyspnoea,  although  the  auscul- 
tatory evidences  of  disease  in  the  chest  may  be  but  small.  This  nervous 
dyspnoea  is  often  relieved  by  the  application  of  a  mustard  poultice  to 
the  chest,  and  by  placing  the  child  in  a  hot  bath — a  proceeding  which 
will  very  frequently  be  followed  by  the  appearance  of  the  rash  abund- 
1  See  Lecture  XX.  p.  233. 


468  TREATMENT   OP   MEASLES. 

antly  over  the  whole  surface.  Should  these  measures,  however,  fail  to 
produce  relief,  or  should  the  symptoms  from  the  first  be  alarming,  the 
distress  and  dyspnoea  very  considerable,  and  the  rash  not  merely  scanty, 
but  of  a  dark  or  livid  hue  wherever  it  has  appeared,  the  abstraction  of 
blood  is  urgently  required ;  and  general  depletion  should,  under  such 
"circumstances,  be  employed  in  preference  to  merely  local  bleeding.  If 
bronchitis  or  pneumonia  should  come  on  at  a  later  period  of  the  disease, 
when  the  rash  has  already  fully  appeared,  or  is  beginning  to  decline, 
the  question  of  bleeding,  as  well  as  of  the  mode  in  which  the  depletion 
shall  be  practised,  must  be  determined  entirely  by  the  severity  of  the 
chest  symptoms,  and  is  little  if  at  all  modified  by  any  considerations 
drawn  from  the  circumstance  of  their  supervening  during  the  course  of 
another  disease.  The  unfavourable  condition  under  which  infants  are 
placed  in  the  H6pital  des  Enfans  at  Paris,  has  induced,  on  the  part  of 
French  physicians,  a  dread  of  depletion  in  the  course  of  measles  which 
is  certainly  not  justified  by  the  characters  that  the  disease  presents  in 
this  country.  A  repetition  of  depletion  is,  however,  not  generally 
either  necessary  or  useful,  especially  if  the  first  abstraction  of  blood  be 
followed  up,  as  it  ought  to  be,  by  the  free  employment  of  tartar  emetic. 
The  dyspnoea,  which  is  frequently  exacerbated  towards  evening  in  the 
course  of  the  pneumonia  and  bronchitis  that  accompany  measles,  is 
generally  much  relieved  by  mustard  poultices ;  but  the  application  of 
blisters  under  these  circumstances  is  hazardous,  since  the  sores  which 
they  produce  are  often  very  intractable ;  and  the  irritation  and  suffering 
they  occasion  prove,  in  many  instances,  seriously  prejudicial  to  the 
children.  It  is  important,  too,  to  bear  in  mind  that  little  reliance  can 
be  placed  on  mercurial  remedies  in  the  treatment  of  active  rubeolous 
pneumonia,  though  small  doses  of  the  Hydr.  c.  Cretai,  with  Dover's 
powder,  are  often  exceedingly  useful  in  cases  where  a  hepatized  state 
of  the  lung  is  left  behind  after  the  subsidence  of  the  fever,  and  of  the 
more  acute  inflammatory  symptoms.  I  spoke  so  fully  some  days  since 
concerning  the  treatment  of  croup  supervening  on  measles,  that  it  can- 
not be  necessary  to  repeat  the  remarks  which  were  then  made ;  neither 
need  I  add  anything  to  what  I  said  on  a  former  occasion  about  cancrum 
oris — which  distressing  affection  occasionally  supervenes  on  the  decline 
of  measles. 

I  will  now,  in  conclusion,  briefly  sketch  the  more  striking  features  of 
scarlet  fever.  To  describe  it  minutely  would  indeed  require  much  time, 
for  there  are  few  diseases  whose  characters  vary  so  widely  in  different 
instances.  In  one  case  it  presents  itself  as  an  ailment  so  trifling  as 
scarcely  to  interrupt  a  child's  cheerfulness  even  for  a  day ;  in  another 
case  it  is  so  deadly  that  medicine  is  unable  to  stay  its  course  even  for 
a  moment ;  and  that  it  destroys  life  in  a  few  days — sometimes  even  in 
a  few  hours.  Such  a  disease  might  seem  to  merit  a  very  minute  inves- 
tigation at  our  hands ;  and  on  this  it  would  be  my  duty  to  enter,  did  I 
not  feel  that,  after  all  that  has  been  written  on  the  subject  of  the 
eruptive  fevers,  it  will  be  enough  for  me  on  the  present  occasion  to 
recal  to  your  recollection  some  of  those  points  concerning  each  of  them, 
which  are  of  the  greatest  practical  moment. 

It  is  hardly  necessary  to  remind  you  that  the  remarkable  differences 
in  the  severity  of  the  affection,  and  in  the  symptoms  which  attend  it, 


SCARLET   FEVER— GREAT   DIFFERENCES   IN   ITS    SEVERITY.  469 

have  given  rise  to  its  subdivision  into  the  three  varieties  of  scarlatina 
simplex,  scarlatina  anginosa,  and  scarlatina  maligna.  In  the  first  of 
these  the  patient  experiences  an  attack  of  fever,  often  very  mild, 
always  of  very  short  duration,  and  accompanied  by  the  appearance  of 
a  bright  scarlet  rash  over  the  whole  surface,  and  generally  by  a  slight 
degree  of  sore  throat.  In  the  second  the  fever  is  more  intense,  and 
subsides  less  speedily,  while,  as  its  name  implies,  the  attendant  sore- 
throat  is  very  severe ;  and  in  the  third  the  fever  generally  assumes  a 
typhoid  character,  sloughing  of  the  inflamed  tonsils  not  infrequently 
occurs,  and  a  variety  of  complications  in  many  instances  supervene, 
by  which  the  danger  is  still  further  aggravated. 

In  cases  of  scarlatina  simplex  the  attack  is  usually  ushered  in  by 
vomiting,  which  is  in  many  instances  often  repeated,  and  which  is 
accompanied  by  very  intense  heat  of  skin,  by  great  rapidity  of  the 
pulse,  by  headache  or  heaviness  of  the  head,  and  by  so  considerable  a 
degree  of  sensorial  disturbance  as  to  give  rise  to  delirium  in  many 
children  wTho  are  old  enough  to  manifest  this  symptom.  On  the  fol- 
lowing day,  often  within  twenty-four  hours  from  the  commencement  of 
the  patient's  illness,  the  rash  of  scarlatina  makes  its  appearance.  It 
usually  shows  itself  first  on  the  neck,  breast,  and  face,  whence  it  extends, 
in  the  course  of  twenty-four  hours,  to  the  trunk  and  extremities.  Its 
oclour  is  a  very  bright  red,  due  in  part  to  a  general  flush  of  the  skin, 
in  part  to  the  presence  of  innumerable  red  dots  or  spots,  which  look 
like  minute  red  papillae,  though  often  they  communicate  no  sense  of 
roughness  to  the  hand.  To  this,  however,  there  are  occasional  excep- 
tions :  the  r\ash  on  the  chest  and  body  presenting  sometimes,  when  at 
its  height,  a\slightly  papular  character ;  and  now  and  then  minute 
sudamina  are  intermingled  with  the  eruption.  In  some  instances  the 
redness  of  the  surface  is  universal,  but  in  other  cases  the  rash  appears 
in  patches  of  uncertain  size  and  irregular  form,  which  never  affect  any 
definite  shape,  and  never  present  a  clearly  circumscribed  margin.  For 
three  days  the  rash  usually  continues  to  become  of  a  deeper  colour,  and 
more  generally  diffused  over  the  whole  surface  ;  it  then  slowly  declines, 
but  does  not  wholly  disappear  until  the  seventh,  or  sometimes  the 
eighth  day  of  the  disease.  The  appearance  of  the  eruption  is  not  in 
general  succeeded  by  any  immediate  diminution  in  the  other  symptoms  ; 
but  on  the  contrary,  they  often  increase  in  severity  until  the  eruption 
has  reached  its  acme,  when  they  slowly  decline  with  the  disappearance 
of  the  rash.  Sometimes,  indeed,  when  the  case  is  very  mild,  the  fever 
abates  so  soon  as  the  rash  is  fully  out ;  and  the  child  regaining  its 
cheerfulness  on  the  third  day,  shews  no  further  signs  of  illness,  though 
the  rash  remains  visible  for  two  or  three  days  longer.  Now  and  then, 
too,  especially  in  young  infants,  the  affection  throughout  consists  of 
little  more  than  of  an  eruption  on  the  skin,  the  presence  of  which  is 
almost  the  only  evidence  of  their  having  been  attacked  by  a  disease 
sometimes  so  deadly.  Such,  however,  are  exceptional  cases  ;  and  in 
most  instances,  even  when  the  disease  is  mild,  a  slight  degree  of  sore- 
ness of  the  throat  comes  on  on  the  second  or  third  day  ;  the  palate  and 
tonsils  appear  red,  and  the  latter  are  generally  somewhat  swollen,  and 
deglutition  is  slightly  impeded.  The  tongue  also  is  preternaturally 
red,  and  its  papillae,  which  are  very  prominent,  project  through  the 


470  SYMPTOMS   OF   SCARLATINA   SIMPLEX. 

white  or  yellowish  fur  which  coats  it,  and  thus  form  an  appearance  as 
characteristic  of  scarlatina  as  the  rash  itself.  The  redness  fades  from 
the  fauces,  and  the  fur  disappears  from  the  tongue,  as  the  eruption 
declines  ;  but  the  prominence  of  the  papillae  often  continues  for  some 
days  longer.  As  the  rash  subsides,  desquamation  of  the  epidermis 
generally  commences,  the  cuticle  peeling  off  from  the  hands  and  feet 
in  large  flakes,  though  on  the  face  and  trunk  the  desquamation  usually 
takes  place  in  furfuraceous  scales.  Both  its  degree  and  duration  vary 
much  in  different  cases ;  sometimes  it  is  over  in  five  or  six  days,  while 
in  other  cases  the  cuticle  is  reproduced,  and  then  desquamates  several 
times  in  succession,  and  the  process  is  thus  protracted  for  three  or  four 
weeks,  or  even  longer.  It  is  not  possible  to  assign  a  cause  for  these 
differences.  Some  epidemics  of  scarlatina  are  characterised  by  the 
abundance  of  the  desquamation,  and  its  almost  universal  occurrence, 
while  at  other  times  it  is  scanty,  and  often  wanting. 

The  danger  of  this  disease  is  by  no  means  in  proportion  to  the  abun- 
dance of  the  rash,  but  rather  to  the  degree  of  the  affection  of  the  throat, 
the  severity  of  which  is  the  distinguishing  feature  of  scarlatina  angi- 
nosa.  In  this  form  of  the  affection  the  premonitory  symptoms  are 
usually  much  more  severe  than  in  the  scarlatina  simplex  ;  they  are 
also  often  of  longer  duration,  the  rash  not  shewing  itself  until  the  end 
of  the  second,  and  sometimes  even  not  until  the  third  day.  It  is, 
moreover,  less  generally  diffused  over  the  surface  than  in  the  milder 
variety  of  the  disease,  but  appears  in  the  form  of  large  scarlet  patches 
irregularly  distributed  over  different  parts  of  the  body,  especially  on 
the  back.  Almost  from  the  commencement  of  the  patient's  illness, 
soreness  of  the  throat  is  experienced,  attended  with  difficulty  of  deglu- 
tition, and  often  with  considerable  stiffness  of  the  neck,  and  pain  and 
difficulty  in  moving  the  lower  jaw,  due  in  part  to  the  swelling  of  the 
submaxillary  glands.  On  examining  the  throat,  it  is  seen  to  be  intensely 
red,  and  the  tonsils  are  both  red  and  swollen.  The  swelling  of  the 
tonsils  increases  rapidly,  until  they  almost  block  up  the  entrance  of 
the  pharynx,  and  thereby  render  the  attempt  to  swallow  so  difficult 
that  fluids  have  often  returned  by  the  nose.  An  adhesive  mucus  col- 
lects about  the  back  of  the  throat,  and  often  seems  to  cause  great 
annoyance  to  the  patient,  and  specks  or  patches  of  lymph  form  upon 
the  tonsils,  and  look  like  sloughs  covering  ulcers,  though,  on  detaching 
them,  it  is  seldom  that  any  breach  of  surface  appears  beneath.  In 
some  of  the  severest  cases,  a  very  troublesome  coryza  comes  on,  and 
an  adhesive,  yellowish,  matter  is  secreted  in  abundance  by  the  mucous 
membrane  of  the  nares,  whence  it  runs  down  upon  the  upper  lip,  exco- 
riating the  skin  over  which  it  passes,  and  causing  still  more  serious 
suffering  by  the  obstacle  which  it  presents  to  free  respiration.  In  some 
epidemics  the  inflammation  extends  to  the  parotid  glands,  and  to  the 
cellular  tissue  about  the  neck,  the  parts  thus  affected  becoming  rapidly 
swollen,  and  acquiring  a  great  size  and  a  stony  hardness.  In  some 
cases  this  affection  is.  confined  to  one  side;  in  others,  both  sides  are 
attacked  in  succession,  while  sometimes  two  are  involved  simultaneously, 
and  the  integuments  under  the  chin  and  in  front  of  the  neck  become 
likewise  inflamed,  and  tense  and  swollen ;  the  lower  jaw  is  so  firmly 
fixed,  that  the  attempt  to  swallow  is  rendered  almost  impracticable, 


SYMPTOMS   OP   SCARLATINA   ANGINOSA.  471 

i 

and  the  patient  is  exposed  to  a  new  source  of  danger,  from  the  diffi- 
culty of  taking  nutriment  in  quantity  sufficient  to  support  the  feeble 
powers  of  life.  Coupled  with  this  severe  local  affection,  there  is,  as 
might  be  expected,  a  corresponding  intensity  in  the  constitutional  dis- 
turbance. The  heat  of  the  skin  is  very  great,  the  pulse  extremely 
frequent,  and,  though  not  small,  is  yet  from  an  early  period  very 
compressed ;  the  sensorial  disturbance  is  considerable,  and  the  rest- 
lessness extreme.  The  tongue  does  not  present  that  appearance  which 
I  mentioned  as  being  characteristic  of  scarlatina  in  its  milder  form,  but 
is  coated  with  a  brown  fur,  though  red  at  its  tip  and  edges,  and  often 
becomes  dry  at  a  very  early  period  of  the  disease, — partly,  no  doubt, 
in  consequence  of  the  swelling  of  the  tonsils  and  of  the  glands  com- 
pelling the  patient  to  breathe  with  his  mouth  open. 

Between  the  severer  forms  of  scarlatina  anginosa  and  that  still  more 
dangerous  variety  of  the  disease  to  which  the  name  of  malignant  has 
been  applied,  the  differences  are  of  degree  rather  than  of  kind.  Symp- 
toms such  as  have  just  been  enumerated  are  present  in  many  cases  of 
malignant  scarlet  fever ;  but  the  fever  very  early  assumes  a  typhoid 
character,  and  death  takes  place  sooner  than  the  amount  of  the  local 
lesions  suffices  to  explain  ;  while  in  the  scarlatina  anginosa  a  direct  pro- 
portion always  exists  between  the  severity  of  the  local  mischief  and  the 
degree  of  constitutional  disturbance. 

A  little  girl,  five  years  old,  went  to  bed  quite  well  on  the  night  of  the 
20th  May,  but  awoke  vomiting  at  4  A.  M.  on  the  21st.  Through  the 
whole  of  the  21st,  the  child  seemed  very  ill,  and  her  bowels  were  much 
purged.  Towards  evening  a  red  rash  appeared  on  her  body,  and  she 
complained  o:f  sore  throat.  On  the  following  day  the  soreness  of  her 
throat  continued,  and  the  submaxillary  glands  began  to  swell.  On  the 
23d  I  saw  her  :  she  was  lying  in  her  mother's  lap,  with  her  face  of  a 
deep  scarlet,  verging  on  a  crimson  hue,  and  the  rash,  which  was  gene- 
rally diffused  over  the  whole  body,  presented  the  same  colour ;  her  eyes 
were  half  open,  and  the  conjunctiva  injected ;  the  submaxillary  glands 
somewhat  swollen  ;  the  tonsils  very  red,  covered  with  shreds  of  mucus  ; 
deglutition  difficult ;  respiration  hurried  ;  pulse  too  frequent  and  too 
feeble  to  be  counted.  She  had  been  delirious  during  the  whole  of  the 
preceding  night.  Ammonia  was  given  in  doses  of  gr.  iij.  every  four 
hours  ;  but  at  4  p.  M.  on  the  24th,  I  found  her  lying  on  her  back  in  a 
semi-comatose  condition,  though  capable  of  being  roused  ;  her  surface 
quite  cool,  of  a  generally  livid  colour;  her  pulse  exceedingly  feeble; 
her  respiration  noisy  and  difficult,  rendered  so  in  part  by  an  abundant 
secretion  of  yellow  adhesive  matter  in  the  nares.  The  swelling  on  the 
right  side  of  the  throat  was  much  the  same  as  on  the  previous  day,  but 
the  left  parotid  was  greatly  swollen  and  of  a  stony  hardness  ;  the  tonsils 
were  more  swollen  ;  deglutition  was  difficult,  and  a  large  quantity  of 
tenacious  mucus  was  collected  about  the  faeces.  The  diarrhoea  still  con- 
tinued, and  at  10  o'clock  the  same  night  the  poor  child  died,  within 
ninety  hours  from  the  commencement  of  her  illness. 

Death  sometimes  takes  place  even  more  rapidly,  at  an  interval  of  less 
than  forty-eight  hours  intervening  between  the  commencement  of  the 
illness  and  its  fatal  close.  In  some  instances  petechise  and  vib'ces 
appear  on  the  surface,  or  haemorrhages  take  place  from  the  bowels, — 


472  SYMPTOMS   OF   SCARLATINA   MALIGNA. 

i 

the  tokens  and  consequences  of  the  changes  in  the  circulating  fluid  ; 
while  convulsions,  succeeded  by  coma,  destroy  the  patient  in  other 
cases,  before  time  has  passed  sufficient  to  allow  of  the  appearance  of 
the  eruption.1  Some  epidemics  of  scarlet  fever  are  characterized  by 
the  frequency  of  these  cases  of  extreme  malignancy,  while  in  others  they 
are  extremely  rare  ;  but  the  general  mildness  of  the  disease  is  no  gua- 
rantee against  their  occasional  occurrence.  During  the  early  part  of 
this  autumn  scarlet  fever  broke  out  in  a  public  institution  some  miles 
from  London.  Almost  all  of  the  cases,  which  occurred  among  lads 
from  14  to  18  years  of  age,  were  extremely  mild  ;  but  one  youth,  more 
robust  than  most  of  the  others,  sank  from  the  moment  he  was  taken,  and 
died  with  typhoid  symptoms  before  the  end  of  the  third  day.  His  case 
stood  by  itself,  unlike  any  of  those  which  preceded  or  which  followed  it. 
Even  in  the  malignant  form  of  scarlatina,  however,  it  is  seldom  that 
death  takes  place  with  this  extreme  rapidity;  but  the  patient  more 
commonly  survives  to  the  end  of  the  sixth  or  seventh  day,  and  under 
these  circumstances  the  affection  of  the  throat  generally  goes  on 
increasing  in  severity.  These  are  the  cases  which  went  during  the  last 
century  under  the  name  of  putrid  sore  throat,  cynanche  maligna, 
angina  putrida;  and  the  occurrence  of  which  constituted  a  marked 
feature  in  the  epidemic  scarlatina  of  1839  and  1843.  The  inflammation 
of  the  tonsils  terminates  in  the  formation  of  excavated,  ragged, 
unhealthy  ulcerations,  which  I  have  occasionally  found,  indeed,  in  the 
pharynx,  and  at  the  upper  part  of  the  oesophagus  ;  or  sometimes  a  more 
extensive  sloughing  involves  the  parts  at  the  back  of  the  throat.  The 
tongue  and  soft  palate  are  found  in  such  cases  denuded  of  their  epithe- 
lium ;  the  papillae  of  the  tongue  very  prominent,  and  those  at  its  base, 
as  well  as  the  lingual  glands  in  that  situation,  extremely  enlarged,  and 
covered  by  a  dirty  tenacious  mucus.  The  coryza,  to  which  reference 
was  made  just  now,  is  generally  very  severe,  while  the  mischief  at  the 
back  of  the  throat  sometimes  extends  to  the  air-passages;  and  I  have 
found  the  mucous  membrane  at  the  under  surface  of  the  epiglottis,  and 
about  the  arytenoid  cartilages,  much  injected  and  thickened :  a  condi- 
tion which,  during  life,  was  sufficient  to  occasion  intense  dyspnoea,  and 
to  give  rise,  on  each  attempt  at  deglutition  during  the  last  twenty-four 
hours  of  the  child's  life,  to  a  struggle  for  breath  which  threatened  every 
moment  to  be  fatal.  The  swelling  of  the  parotids  in  some  of  these 
cases  increases  with  very  great  rapidity,  and  forms  not  unfrequently, 
by  the  implication  of  the  integuments  of  the  neck,  a  sort  of  collar  of 
brawny  hardness,  which  interferes  alike  with  deglutition  and  respiration. 
These  swellings  are  remarkable  for  the  slight  tendency  which  they 
show  to  suppurate  ;  and  even  after  they  have  attained  a  very  consider- 
able size,  and  been  in  great  measure  instrumental  in  occasioning  the 
child's  death,  I  have  found  the  parotids  much  enlarged,  of  a  rose  red 
colour,  infiltrated  with  thin  serum,  and  a  dirty  sero-purulent  fluid  also 
pervading  the  cervical  cellular  tissue,  but  no  true  pus  either  in  the 
substance  of  the  gland  itself  or  in  the  surrounding  cellular  tissue.  Now 
and  then,  however,  suppuration  takes  place,  not  in  the  substance  of  the 
glands  themselves,  but  in  the  surrounding  cellular  tissue ;  and  the 
quantity  of  pus  which  is  formed  there  is  sometimes  very  considerable. 
1  Of  which  a  case  is  related  in  Lecture  III.  p.  35. 


COMPLICATIONS   OP   SCARLET  FEVER."]  473 

The  destruction  of  tissue,  too,  is  not  always  the  result  of  mere  suppura- 
tion, but  a  process  of  sloughing  sometimes  destroys  the  cellular 
membrane  very  extensively ;  and,  by  involving  the  large  vessels  of  the 
neck,  has  sometimes  caused  the  child's  sudden  death  from  haemorrhage 
— an  occurrence,  indeed,  which  I  have  not  met  with,  but  which  came 
thrice  under  the  observation  of  Dr.  H.  Kennedy,  of  Dublin,  whose 
excellent  account  of  the  epidemic  which  prevailed  in  that  city  will  well 
repay  your  attentive  perusal. 

As  in  other  blood  diseases,  so  in  scarlatina,  we  meet  now  and  then 
with  secondary  inflammation  of  the  joints,  which  may  even  go  on  to  the 
formation  of  pus.  It  is,  however,  not  a  common  occurrence ;  but  I  saw 
the  hand  thus  affected  in  a  child  who  died  on  the  sixth  day  of  the 
disease,  and  in  another  child,  who  had  recovered  from  scarlatina  in  the 
course  of  which  inflammation  attacked  the  right  shoulder-joint,  the 
humerus  remained  perfectly  anchylosed.  Both  the  pericardium  and 
endocardium  are  also  sometimes  affected,  but  in  this  stage  of  the  disease 
that  special  tendency  to  inflammation  of  the  serous  membranes  which 
is  afterwards  observed  does  not  manifest  itself.  Pneumonia,  indeed,  is 
a  more  frequent  affection,  running  its  course  without  any  marked 
symptom,  though  a  large  portion  of  one  or  both  lungs  may  be  found 
after  death  in  a  state  of  hepatization. 

The  other  post-mortem  appearances  observed  in  scarlatina  are  to  a 
great  degree  identical  with  those  observed  in  malignant  fevers  generally. 
The  blood  is  usually  semi-coagulated,  of  the  appearance  and  consistence 
of  gooseberry-jelly,  or  even  altogether  fluid,  and  the  coats  of  the  vessels 
are  often  stained  by  it.  The  mucous  membrane  of  the  bronchi,  stomach, 
oesophagus,  and  trachea,  is  often  of  an  intensely  red  colour,  though 
nothing  can  be  more  arbitrary  than  the  extent,  degree,  and  situation  of 
this  redness.  The  texture  of  the  kidneys  and  heart  is  also  often  very 
much  softer  than  natural,  so  as  to  tear  very  readily;  and  once  I  found 
the  heart  exceedingly  flaccid,  its  tissue  infiltrated  with  reddish  serum ; 
and  not  merely  tearing  easily,  but  even  being  so  soft  that  the  finger 
could  be  pushed  through  its  walls  with  the  slightest  effort. 

Such  are  the  chief  modes  of  death  from  scarlet  fever,  and  such  the 
more  important  appearances  discovered  afterwards :  at  least  as  far  as 
my  personal  observation  extends, — though  I  scarcely  need  remind  you 
that  there  are  but  few  diseases  of  which  the  characters  are  liable  to 
greater  variations ;  so  that  no  account  how  minute  soever  can  be  taken 
as  a  true  portraiture  of  more  than  just  that  one  form  of  the  fever  with 
which  its  describer  may  chance  to  be  most  familiar. 

Unhappily  the  first  few  days  of  the  disease  do  not  by  any  means  com- 
prise the  whole  period  of  danger,  but  even  though  the  patient  should 
survive  the  peril  of  the  fever,  a  long  catalogue  of  sequelae  remains,  some 
of  which  may  endanger  or  even  destroy  life.  Sometimes,  indeed,  the 
patient  passes  through  the  first  week  of  the  disease  with  few  or  no 
symptoms  to  excite  anxiety;  and  then,  when  the  rash  is  on  the  decline, 
the  parotid  glands  swell,  grow  hard,  and  intensely  painful,  and  on  one 
or  two  occasions  I  have  seen  the  integuments  covering  them  become 
gangrenous  ;  or  sloughing  ulcers  form  on  the  tonsils,  which  had  not 
seemed  to  be  very  much  inflamed  previously ;  an  acrid  discharge  takes 
place  from  the  nostrils,  and  death  follows  in  the  course  of  four  or  five 


474  SEQUELS  OP  SCARLET  FEVER. 

days.  In  the  majority  of  instances,  however,  the  glandular  swellings 
which  come  on  after  the  lapse  of  a  week  from  the  commencement  of  the 
disease,  though  tedious  and  painful,  yet  do  not  endanger  life.  Occa- 
sionally, indeed,  death  occurs  in  consequence  of  the  matter  formed  by 
the  inflammation  of  the  glands,  or  of  the  cellular  tissue  around  them, 
burrowing  backwards  behind  the  pharynx,  instead  of  pointing  exter- 
nally. In  these  cases  of  retro-pharyngeal  abscess,  after  more  or  less 
evident  indications  of  inflammation  in  the  neighbourhood  of  the  parotid 
or  submaxillary  glands,  accompanied,  in  all  probability,  with  a  swelling 
on  one  or  other  side  of  the  neck  or  jaw,  the  patient  begins  to  experi- 
ence difficulty  in  deglutition,  which  goes  on  increasing  until  the  attempt 
to  swallow  becomes  quite  impracticable.  As  the  dysphagia  increases, 
respiration  becomes  also  very  difficult,  but  the  dyspnoea  continues  to 
increase  progressively,  and  is  not  aggravated  in  paroxysms,  as  in  cases 
of  cynanche  trachealis,  though  the  effort  to  swallow  will  sometimes 
bring  on  threatening  suffocation.  Moreover,  there  is  seldom  any  modi- 
fication in  the  tone  of  the  voice,  such  as  occurs  in  croup,  though  the 
voice  becomes  by  degrees  whispering  and  then  extinct;  while  if  the 
throat  be  examined,  the  tonsils  are  observed  to  be  free  from  swelling ; 
and  sometimes  neither  they  nor  the  soft  palate  show  the  slightest  in- 
crease in  redness  or  other  token  of  inflammation.  These  general  symp- 
toms, coupled  with  the  negative  results  afforded  by  examination  of  the 
fauces,  point  tolerably  plainly  to  the  real  nature  of  this  affection ;  but 
positive  certainty  concerning  it  can  be  obtained  only  by  a  means  which 
Mr.  O'Ferrall,  of  Dublin,  was,  to  the  best  of  my  knowledge,  the  first 
to  point  out,  and  which  consists  in  passing  the  finger  for  some  distance 
down  the  throat,  when  the  presence  of  a  tumor  pressing  forward  the 
posterior  wall  of  the  pharynx  or  oesophagus,  will  at  once  reveal  the 
cause  of  the  patient's  sufferings. 

Coupled  with  the  swelling  of  the  parotid  glands,  or  even  indepen- 
dently of  it,  inflammation  of  the  internal  ear  is  often  met  with  as  a 
consequence  of  scarlatina.  This  otitis  terminates  in  abundant  purulent 
discharge,  which  sometimes  continues  for  many  weeks;  and  occasionally 
it  completely  destroys  the  organ  of  hearing,  and  renders  the  patient 
hopelessly  deaf  for  the  remainder  of  his  life. 

I  have  already  spoken,  in  a  previous  lecture,1  of  that  very  frequent 
and  very  serious  occurrence,  the  dropsy  which  succeeds  to  scarlet  fever, 
and  need  not,  therefore,  refer  to  that  subject  now.  But  there  are  other 
cases,  in  which,  without  any  definite  local  complication,  the  convales- 
cence from  scarlet  fever  is  fluctuating  and  protracted.  In  such  cases 
the  bowels  are  irregular  in  their  action,  alternately  relaxed  and  consti- 
pated ;  the  evacuations  unhealthy ;  the  tongue  red  and  raw ;  and  aph- 
thous ulcerations  sometimes  appear  on  the  inside  of  the  mouth ;  while 
an  irregularly  remittent  fever  harasses  and  weakens  the  child.  These 
symptoms,  however,  which  closely  resemble  those  that  sometimes  come 
on  during  convalescence  from  measles,  are  of  much  less  frequent  occur- 
rence as  consequences  of  scarlatina. 

The  diagnosis  of  scarlatina  is  not  in  general  attended  with  much 
difficulty  ;•  and  the  points  of  difference  between  it  and  measles  are  so 
well  marked,  that  it  is  not  easy  to  understand  how  the  two  diseases 
I  See  Lecture  XXXV.  p.  419. 


DIAGNOSIS   OF   SCARLET   FEVER.  475 

should  so  long  have  been  confounded  together.  Their  period  of  incu- 
bation is  different ;  that  of  scarlatina  not  exceeding  a  week,  that  of 
measles  often  extending  to  two.1  Their  premonitory  symptoms  are 
very  dissimilar — those  of  measles  closely  resembling  the  signs  of  a 
severe  catarrh  ;  while  the  attack  of  scarlatina  is  announced  by  sickness, 
succeeded  by  intense  heat  of  skin,  by  sore  throat,  great  sensorial  dis- 
turbance, and  extreme  rapidity  of  the  pulse.  There  is  no  other  disease 
of  childhood,  indeed,  in  which  the  two  last-named  symptoms  supervene 
so  speedily  after  the  commencement  of  illness ;  and  their  occurrence 
will  often  enable  you,  even  before  the  appearance  of  the  rash,  or  any 
complaint  of  sore-throat,  to  form  a  correct  conclusion  with  reference  to 
the  nature  of  the  affection.  The  premonitory  stage  of  measles  usually 
continues  for  three  or  four  days — that  of  scarlet  fever,  in  its  regular 
form,  only  for  twenty-four  hours;  while  the  other  symptoms  which 
appear  in  cases  of  scarlet  fever,  in  which  the  rash  is  delayed,  are  such 
as  quite  to  forbid  the  supposition  of  the  patient  being  affected  with 
measles.  The  character  of  the  two  eruptions  is  so  dissimilar,  that  I 
need  not  here  dwell  on  their  peculiarities,  nor  do  more  than  remind  you 
that,  while  in  measles  the  great  danger  to  life  arises  from  the  super- 
vention of  bronchitis  or  pneumonia,  the  two  great  sources  of  hazard  in 
scarlet  fever  are  the  affections  of  the  throat  during  its  progress,  and  the 
occurrence  of  dropsy  after  its  decline. 

With  a  few  words  on  the  treatment  of  scarlatina,  I  will  bring  this 
subject,  and  the  present  course  of  lectures,  to  a  close.  The  milder 
forms  of  the  disease  require,  as  you  know,  but  little  interference ;  and 
you  fulfil  every  indication  by  keeping  the  child  in  a  cool  and  well-ven- 
tilated chamber,  placing  him  on  a  spare  diet,  giving  some  mild  anti- 
phlogistic medicine  during  the  progress  of  the  fever,  and  sponging  the 
surface  occasionally  with  tepid  water  if  the  heat  of  the  skin  be  consi- 
derable. When  the  eruption  is  on  the  decline,  the  hot  bath  every  night 
is  often  very  useful  in  favouring  the  process  of  desquamation  ;  while 
the  child  must  be  kept  strictly  within  doors,  his  diet  must  still  be  mild 
and  unstimulating,  and  due  attention  must  be  paid  to  the  state  of  the 
bowels,  until  the  period  has  passed  when  there  is  much  ground  for 
fearing  the  supervention  of  dropsy.  For  some  time  after,  much  caution 
must  be  exercised  in  not  allowing  the  child  to  go  out  when  the  air  is 
coo?,  and  in  avoiding  all  errors  of  diet ;  while  it  is  also  expedient  that 
flannel  should  be  worn  next  the  skin  for  a  considerable  period  after 
apparent  convalescence  from  scarlet  fever. 

Even  in  severer  cases  of  the  disease,  you  must  not  be  in  too  great  a 
hurry  to  resort  to  active  measures,  for  you  will  remember  that  a  some- 
what stormy  onset  is  characteristic  of  all  but  the  very  mildest  forms  of 
scarlatina.  That  disturbance  of  the  sensorium,  for  instance,  which, 
when  the  child  is  sufficiently  old,  shows  itself  by  the  early  occurrence 
of  delirium,  must  not  lead  you  to  have  recourse  hastily  to  depletion, 
either  general  or  local,  in  order  to  quiet  the  disorder  of  the  brain.  The 
results  afforded  by  depletion  in  scarlet  fever,  even  when  the  disease 

1  I  have  purposely  omitted  to  say  any  thing  concerning  the  diagnosis  between  scar- 
latina and  the  kindred  exanthema,  called  Rotheln  by  German  writers  (the  Rubeola  of 
some  continental  nosologists) ;  for,  though  I  believe  there  to  be  a  foundation  for  this 
distinction,  my  own  opportunities  have  not  enabled  me  to  come  to  any  positive  conclu- 
sion on  the  subject. 


476  TREATMENT   OP   SCARLET   FEVER. 

occurs  in  the  adult,  are  by  no  means  encouraging  ;  and  in  the  child  the 
loss  of  blood  under  these  circumstances  is  even  less  well  borne  ;  so  that, 
unless  the  patient  be  robust  and  plethoric,  the  cerebral  disturbance  very 
serious,  and  the  evidences  of  congestion  of  the  brain  very  marked,  you 
should  content  yourselves  with  the  application  of  cold  to  the  head,  per- 
haps employing  cold  affusion,  and  with  cold  sponging  of  the  surface. 
In  the  malignant  forms  of  the  disease  there  is  often  very  considerable 
disturbance  of  the  sensorium,  great  restlessness  alternating  with  a  state 
of  stupor ;  but  the  frequent  and  feeble  pulse  at  once  forbids  depletion 
in  such  cases  and  points  out  the  necessity  for  adopting  every  means  to 
support  the  feeble  powers  of  life.     If  there  be  much  sore-throat,  and  the 
child  seem  likely  to  bear  the  loss  of  a  little  blood,  I  sometimes  apply  a 
few  leeches  to  the  angle  of  the  jaw ;  but  have  hardly  ever  carried  deple- 
tion beyond  this  point  among  my  patients  at  the  Children's  Infirmary. 
It  is  very  likely  that  the  low  type  which  a  disease  such  as  scarlatina  is 
almost  sure  to  assume  in  the  crowded  dwellings  of  the  poor,  has  ren- 
dered my  practice,  in  this  respect,  somewhat  different  from  that  which 
might  be  advantageously  pursued  in  the  case  of  children  more  favour- 
ably situated.     To  the  same  circumstances  it  is  also  probably  due  that, 
in  a  large  proportion  of  cases,  I  have  found  it  desirable  to  give  ammonia 
almost  from  the  outset  of  the  disease ;  a  practice  which  has  been  recom- 
mended as  universally  applicable,  and  which  (though  the  remedy  does 
not  deserve  the  indiscriminate  encomiums  that  have  been  lavished  on  it) 
you  will  do  well  to  follow,  whenever  the  pulse  presents  the  characters 
of  great  frequency  and  softness  combined.     The  state  of  the  throat  must 
be  carefully  watched  in  every  case  of  scarlet  fever ;  and  whenever  there 
is  much  swelling  of  the  tonsils,  if  the  child  be  too  young  to  gargle,  a 
slightly  acidulated  lotion  should  be  injected  into  the  throat,  by  means 
of  a  syringe,  every  few  hours,  in  order  to  free  it  from  the  mucus  which 
is  so  apt  to  collect  there,  and  to  be  the  source  of  much  discomfort.     If 
there  be  much  deposit  of  lymph  upon  the  tonsils,  it  is  generally  desirable 
to  apply  the  strong  hydrochloric  acid,  mixed  with  honey,  in  the  propor- 
tion of  about  one  part  of  the  former  to  six  of  the  latter,  by  mea'ns  of  a 
dossil  of  lint,  or  a  camel's  hair  pencil,  two  or  three  times  in  the  twenty- 
four  hours ;  but  the  strength  of  the  application  must  be  increased  if  the 
tonsils  be  ulcerated,  or  if  any  disposition  to  sloughing  should  appear. 
The  coryza  which  is  so  distressing  and  so  ill-omened  a  symptom  in 
cases  of  severe  scarlatina,  is  best  treated  by  throwing  a  small  quantity 
of  a  solution  of  gr.  j.  or  gr.  ij.  of  nitrate  of  silver  in  Ij.  of  distilled 
water,  up  the  nostrils  every  four  or  every  six  hours.     The  glandular 
swellings  are  very  difficult  to  relieve.     When  considerable  they  do  not 
seem  to  be  benefited  by  leeches  ;  the  employment  of  which  is  also,  in 
many  cases  contraindicated  by  the  feeble  state  of  the  patient's  powers  ; 
while  they  show  very  little  disposition  to  suppurate,  and  consequently 
are  not  relieved  by  lancing :  so  that  the  constant  application  of  a  warm 
poultice  is  often  all  that  can  be  done  to  afford  ease  to  the  patient. 
Children  in  whom  the  local  affection  is  severe,  or  in  whom  the  disease 
assumes  a  malignant  character,  require  all  those  stimulants,  and  that 
nutritious  diet,  which  we  are  accustomed  to  give  to  patients  in  certain 
stages  of  typhus  fever ;  though,  unfortunately,  the  best  devised  means 
will,  in  many  such  cases,  prove  ineffectual. 


INDEX. 


Abdomen,  examination  of,  in  sick  children,  20. 

shrunken,  in  acute  hydrocephalus,  68. 
Abdominal  Tumours,   from   general    enlarge- 
ment of  abdomen,  430. 
suspected   sometimes  when  not  present, 

436. 
from  enlarged  liver — case,  432. 
hydatids  of  the  liver — case,  432. 
fungoid  disease  of  the  liver — case,  434. 
kidney — case,  434. 

psoas  abscess,  caution  as  to  diagnosis,  435. 
^  enlargement  of  the  spleen,  435. 
Acute  Hydrocephalus,  56. 

see  Hydrocephalus. 
Air,  vitiated,  cause  of  infantile  trismus,  132. 
Albuminuria,  419. 

see  Kidneys,  inflammation  of. 
Alkalies,  their  use  in  infantile  dyspepsia,  363. 
Anasmia,  bruits  due  to,  very  rare  in  child,  313. 
Antimony,  in  treatment  of  bronchitis,  188. 
pneumonia,  201. 
croup,  225,  256. 
dropsy  after  scarlatina,  424. 
and  Opium,  in  head  symptoms  of  remit- 
tent fever,  452. 
Anus,  prolapsus  of,  in  course  of  chronic  diar- 
rhoea, treatment  of,  401. 
imperforate,  374. 
see  Rectum,  imperforate. 
Aphtha?,  335. 

see  Thrush. 
Apoplexy,  symptoms  less  dangerous  in  child 

than  in  adult,  46. 
Arachnoid,   peculiar   condition   of,   in    acute 
hydrocephalus,  59. 
granulations  of,  in  hydrocephalus;  their 

tubercular  nature,  61. 
lining  of  the  ventricles,  granular  state  of, 

94. 
haemorrhage  into  the,  47,  51. 
ch.  nges  of  the  effused  blood,  51. 
obscurity  of  its  symptoms,  52. 
cases  of,  53. 

chronic  hydrocephalus  an  occasional  re- 
sult of,  52,  97. 
Asphyxia,  of  new-born    child,  often   due   to 
cerebral  haamorrhage,  47. 
treatment  of,  47. 
Asthma  Thymicum,  244. 

see  Spasm  of  the  Glottis. 
Astringents,  use  of,  in  treatment  of  diarrhoea, 

399. 
Atelektasis  Pulmonum,  151. 

see  Lungs,  imperfect  expansion  of. 
Atrophy  of  Brain,  107. 

see  Brain,  atrophy  of. 
Auscultation,  general  rules  for,  20. 


B. 


Blisters  in  treatment  of  acute  hydrocephalus, 
81. 
pneumonia,  203. 
croup,  228. 
hooping-cough,  273. 
Brain  in  infancy,  peculiarities  of  its  circula- 
tion, 27. 
controlling  power  over  spinal   cord  not 

manifest,  31. 
disease  of,  symptoms  of,  29. 
importance   of   vomiting  as   a  sign    of, 

30,  38. 
paralysis  from,  diagnosis  of,  145. 
disorder  of,  sympathetic,  in  pneumonia, 

113. 
in  jaundice,  symptoms  of,  373. 
Atrophy  of,  with  premature  ossification  of 
skull,  107. 
in  course  of  long  illness,  107. 
partial — case  of,  109. 
Cancer  of,  122. 
Congestion  of,  34. 

see  Congestion  of  the  Brain. 
Dropsy  of,  56. 

see  Hydrocephalus. 
Ha3morrhage  into  substance  of — cases  of, 
54. 
see  Cerebral  Haemorrhage. 
Hydatids  of,  122. 
Hypertrophy  of,  101.    , 
illustrative  case,  and  symptoms  of,  103. 
its   connection   with    rickets,    cretinism, 

and  idiocy,  103. 
state  of  brain  in,  104. 
diagnosis  from    chronic    hydrocephalus, 

104. 
occasional  cure  of  chronic  hydrocephalus 

by,  97. 
treatment  of,  105. 
partial,  107. 
Inflammation  of,  deaths  from,  at  different 
ages,  56. 
progress  of  knowledge  concerning,  57. 
two  kinds  of,  simple  and  scrofulous,  58. 
consequent  on  disease  of  bones  of  skull, 

81. 
see  Encephalitis  and  Hydrocephalus, 
sinuses  of — case  of,  88. 
Malformation  of,  107. 

connection  of  chronic  hydrocephalus  with, 
91,  93,  97,  98. 
Softening  of,  in  hydrocephalus,  not  due  to 

imbibition,  62. 
Tubercle   of,  its  frequency  in    childhood, 
115,  117. 
anatomical  characters  of,  115. 
changes  it  undergoes,  116. 


478 


INDEX. 


Brain  in  infancy, 

Tubercle  of,  capillary  apoplexy  in,  56. 
in  cases  of  acute  hydrocephalus,  64. 
symptoms  of,  very  obscure,  117,  119. 
sometimes  absent,  sometimes  very  sudden 

in  their  occurrence,  11 S. 
peculiar  character  of  convulsions  in,  33. 
varieties  in  course  of  the  disease,  120. 
deposit  occasionally  external  to  brain — 

case,  121. 
diagnosis,  121. 

treatment  of  suspected  cases  of,  121. 
Ventricles    of,   changes    of  their  lining  in 

acute  hydrocephalus,  63. 
Bronchial  Phthisis,  anatomical  characters  of, 

283. 
,  process  of  cure  of,  284. 
perforation  of  bronchi,  &c,  285. 
symptoms  of,  287,  292. 
auscultatory,  peculiarities   of,   289,   292, 

293. 
exaggerated  by  intercurrent  bronchitis, 

292. 
occasional  recovery  from,  288. 
modes  of  death  in,  288. 
Bronchitis,  points  of  difference  in  child  and 

adult,  171. 
morbid  appearances  of  bronchi  in,  172. 
dilatation  of  bronchi  in,  173. 
nature  of  vesicular,  174. 
morbid  appearances,  affection  of  pulmo- 
nary tissue  in,  174. 
symptoms  of,  183. 

similar  to  those  of  pneumonia,  175, 197. 
sudden  supervention  of  collapse  of  lungs 

in,  183. 
when    chronic,   may    simulate    phthisis, 

190. 
intercurrent,   exaggerates    symptoms    of 

phthisis,  295. 
treatment  of,  depletion  in,  187. 
tartar  emetic  in,  188. 
nervous  dyspnoea  in,  189. 
convalescence  from,  190. 
complicating  measles,  treatment  of,  470. 
hooping-cough,  257. 
treatment  of,  275. 
inflammatory  diarrhoea,  390. 
Capillary,  its  nature  and  symptoms,  184. 
case  illustrative  of,  186. 
results  of  auscultation  in,  187. 
average  duration  of,  187. 
treatment  of,  190. 
Bronchio-pneumonia,  import  of  the  term,  172, 

192. 
its  symptoms,  196. 


C. 


Calculus,  frequency  of,  in  childhood,  424. 

symptoms  of,  425. 

treatment  of,  426. 
Cancer  of  brain,  121. 

kidney,  434. 

liver,  443. 

lung,  435. 
Cancrum  oris,  349. 

see  Stomatitis,  gangrenous. 
Case-taking,  rules  for,  23. 
Castor  Oil,  use  of  small  doses  of,  in  diarrhoea, 
396. 


Catarrh,  influence  of  age  and  of  season  of  year 
in  its  production,  170. 
its  special  importance  in  infancy,  181. 
symptoms  of,  170. 
treatment  of,  171. 
Suffocative,  184. 

see  Bronchitis,  capillary. 
Cephalhematoma,  its  character  and  changes, 
48. 
case  illustrating  process  of  cure  of,  49. 
diagnosis  and  treatment  of,  50. 
subaponeurotic,  50. 
Cerebral   Circulation,  its  peculiarities  in  in- 
fancy, 27. 
Congestion,  34. 

see  Congestion  of  the  Brain. 
Croup,  248. 

see  Spasm  of  the  Glottis. 
Haemorrhage,  46. 

frequent  cause  of  asphyxia,  47. 
into  Substance  of  Brain,  54. 
generally  capillary,  47. 
capillary  in  cases  of  tubercle,  56. 
into  Sac  of  Arachnoid,  48,  51. 
treatment  of,  56. 
external  to  Skull,  48. 
see  Cephalhaamatoma. 
Bespiration,  meaning  of  the  term,  30. 
Chest,  elasticity  of  walls  of,  149. 

examination  of,  in  sick  children,  20. 
Chicken  pox,  essential  differences  from  Small- 
pox, and  symptoms,  463,  464. 
Children,  high  mortality  of,  17. 

peculiarities  of  their  diseases,  18. 
rules  for  conducting  examination  of,  19. 
feebleness  of  inspiratory  power  in,  149. 
imperfect   expansion    of    lungs   in    new- 
born, 150. 
Chlorate  of  potash,  in  treatment  of  stomatitis, 

344,  349. 
Chorea,  rare  in  early  childhood,  138. 

influence  of  sex  and  other  causes  in  pro- 
ducing it,  138. 
its  treatment,  139. 
partial — case  of,  139. 
Chronic  Hydrocephalus,  90. 

see  Hydrocephalus. 
Cod-liver  Oil,  in  treatment  of  phthisis,  302. 
Cold,  influence  of  exposure  to,  149. 
mode  of  applying  to  head,  41. 
external  application  of,  in  acute  hydro- 
cephalus, 80. 
Affusion  in  congestion  of  brain,  41. 
Congestion  of  the  Brain,  its  frequency,  34. 
first  stage  of  many  cerebral  diseases,  35, 

38. 
apparent,  how  distinguished  after  death 

from  real,  58. 
fatal,  may  leave  very  slight  post-mortem 

appearances,  35. 
active,  causes  of,  35. 
cases  of  at  onset  of  eruptive  fevers,  35. 
case  of,  from  exposure  to  sun,  37. 
symptoms  of,  37. 
its  stages  and  modes  of  termination,  38, 

39. 
treatment  of,  39,  40. 
rules  for  depletion  in,  40. 
use  of  purgatives  in,  40. 
cold  affusion  in,  41. 
passive,  causes  of,  35,  44. 


INDE  X. 


479 


Congestion  the   of  Brain,  case  illustrative  of 

symptoms  of,  43. 
treatment  of,  39,  44. 
Constipation,  from  congenital  malformation  of 

intestines,  373. 
strangulated  hernia,  379. 
intussusception,  379. 

see  Eectum,  imperforate,  and  Intussus- 
ception, 
Convulsions  in  child  answer   to  delirium  in 

adult,  31. 
deaths  from,  at  different  periods  of  life, 

(note)  32. 
due  to  predominance  of  spinal  system  in 

early  life,  31. 
description  of  a  fit  of,  34. 
importance  of  ascertaining  their  cause,  32. 
in  hydrocephalus,  68,  69. 
occur  from  slight  causes,  28,  31,  32. 
independent  of  disease  of  brain,  136. 
complicating  hooping-cough,  260. 
from  intestinal  worms,  418. 
malaria,  393. 
Copper,   Sulphate  of,   in  advanced  stages   of 

croup,  226.   - 
Coryza,  symptoms  of,  167. 

malignant,  case  in  illustration  of,  168. 
its  treatment,  169. 
its  connection  with  syphilis,  169. 
sometimes    sole    symptom    of    infantile 

syphilis,  438. 
Cough,  peculiar,  in  disease  of  brain,  30. 
at  onset  of  hydrocephalus,  70. 
paroxysmal,  in  course  of  capillary  bron- 
chitis, 185. 
bronchial  ^phthisis,  287. 
spasmodic,  in  bronchial  phthisis,  intestinal 

rritation,  cerebral  inflammation,  247. 
peculiar,  in  croup,  218. 
Cretinism,  connection  of,  with  hypertrophy  of 

brain,  103. 
Croup,  definition  of  the  disease,  214. 

character,  influenced  by  various  causes, 

214. 
peculiarity  of  the  field  in  which  the  au- 
thor's observations  were  made,  (note), 

214. 
influence   of  age,   sex,   climate,   &c,  in 

causing  it,  215. 
prevails  epidemically,  216. 
morbid  appearances,  modified  by  locality, 

216. 
observations  of  the  author,  217. 
N  peculiarities  in  croup  after  measles,  217. 
symptoms  of,  onset,  and  first  stage,  218. 
second   stage,   pathognomonic    sound   of 

voice  and  cough,  218. 
third  stage,  delusive  appearances  of  im- 
provement, 220. 
results  of  auscultation  in,  221. 
spasmodic  dyspnoea  in,  225,  237,  238. 
duration  of,  and  prognosis  in,  221,  222. 
treatment  of,  premonitory  symptoms  of, 

222. 
depletion  in,  223. 
employment  of  antimony  in,  224. 
calomel  in,  225. 
inflammation  of  lungs  in  course  of  croup, 

225. 
danger  of  over-treatment  in,  225. 
convalescence  from  the  disease,  225. 
advanced  stages  of,  226. 


Croup,  of  uso  sulphate  of  copper  in,  227. 

caution  with  reference  to  emetics  in,  227. 

use  of  blisters  in,  228. 

bronchotomy  in,  228. 

difference    of   results    in    England    and 

France,  228. 
reasons  for  not  rejecting  it,  229. 
asthenic   variety   of,   influence   of   local 

causes  in  predisposing  to  it,  232. 
its    symptoms,    probable    identity    with 

diphtheritis,  232. 
occurrence  as  a  sequela  of  measles,  233. 
post-mortem  appearances  in,  235. 
treatment  of,  235,  237. 
cauterization  of  larynx  in,  236. 
with  predominance  of  spasmodic  symp- 
toms, 237. 
illustrative  case,  238. 
Spasmodic,  239. 
see  Spasm  of  the  Glottis. 
Cri  Hydrencephalique,  67. 
Cry  in  infancy,  its  two  periods,  22. 

characteristic,  in  imperfect  expansion  of 
the  lungs,  153. 
Cyanosis,  cases  of,  313. 

Cynanche    Laryngea,    Cynanche   Tra<ehealis, 
214. 
see  Croup. 
Parotidea,  symptoms  of,  357. 

treatment  of,  358. 
Tonsillaris,  354. 


D. 


Dentition,  tardy  in  human  subject,  325. 
order  of  appearance  of  the  teeth,  340. 
pauses  in  its  course,  247,  341. 
development  of  digestive  system  during, 

382. 
disease  frequent  during,  18. 
high  mortality  during,  and  reasons  for  it, 

33'9. 
affections  of  mouth  during,  341. 
connection  of,  with  diarrhoea,  381. 
congestion  of  brain,,  frequent  during,  37, 

38. 
occurrence  of  paralysis  during,  141. 
connection  of,  with  spasm  of  the  glottis, 

243. 
diagnosis     of    pneumonia     supervening 

during,  199. 
dysuria  during,  425. 
treatment,  use  of  the  gum-lancet,  342. 
constitutional,  343. 
treatment  of  affections  of  mouth  during, 

343. 
of  eruptions  of  scalp,  &c,  caution  con- 
cerning, 344. 
of  diarrhoea  during,  375. 
Depletion  in  congestion  of  brain,  40. 
in  acute  hydrocephalus,  78. 
in  bronchitis,  187. 
in  pneumonia,  200. 
in  pleurisy,  212. 
in  croup,  224. 

from  head  in  hooping-cough,  272,  274. 
in  spasm  of  the  glottis,  248. 
in  inflammatory  diarrhoea,  396. 
in  tubercular  peritonitis,  414. 
from  head  in  remittent  fever,  453. 
in  affections  of  chest  in  course  of  measles, 

476. 


480 


INDEX. 


Depletion,  caution  concerning,  in  affection  of 

head  in  scarlet  fever,  475. 
in  dropsy  after  scarlet  fever,  424. 
excessive,  its  peculiar  dangers  in  infancy, 

27,  114. 
Diabetes,  rarity  of,  in  childhood,  428. 

symptoms  of,  connection  with  dyspepsia, 

428. 
treatment  of,  429. 
Diarrhoea,,  its  frequency  and  importance,  380. 
table  illustrating,  381. 
influence  of  age  on  ;  of  dentition,  381. 
season  on,  382. 

locality  on  ;  malaria,  383,  393. 
two  forms  of,  381. 

simple  or  catarrhal,  symptoms  of,  382. 
during  teething,  383. 
danger  from  exhaustion,  383. 
of  supervention  of  dysentery,  384. 
inflammatory,  or  dysentery,  384. 
its  resemblance  to  dysentery  in  the  adult, 

385. 
morbid  appearances,  chiefly  in  large  in- 
testine, 385. 
in  other  parts,  386. 
symptoms  of  acute  attack  of,  387. 
occasional  rapidity  of  course  of,  388. 
chronic  course  of,  389. 
various  causes  and  modes  of  death  from, 

390. 
relapses  of,  390. 
supervention  of  cerebral  symptoms  from 

exhaustion  in  course  of — cases,  263. 
complicating  hooping-cough,  263. 
sometimes  associated  with  congestion  of 

brain,  43. 
possibility  of  its  occurrence  in  hydroce- 
phalus, 89. 
treatment  of  simple  form,  393. 
during  teething,  394. 
in  its  decline,  395. 
inflammatory  form  ;  depletion,  396. 
vomiting,  and  of  nervous  symptoms,  397. 
use  of  stimulants  in,  398. 
aromatics  and  astringents,  399. 
chronic  stage  of,  399. 
diet  in,  400. 
intertrigo  in,  401. 
prolapsus  ani  in,  401. 
Diphtheritis,  232. 

see  Croup. 
Digestive  System,  peculiarities   of,  in   early 

childhood,  335. 
form,  331. 
changes  in,  with  advancing  years,  338, 

382. 
deaths  from  diseases  of,  and  from  other 

causes,  compared,  (note),  147. 
disorder  of,  associated  with  diabetes,  483. 
Disease,  peculiarities  of,  in  childhood,  18. 
difficulties  of  investigating,  18. 
how  to  investigate,  19. 
hereditary  tendency  to,  important,  23. 
Dropsy  after  Scarlatina,  419. 

see  Kidneys,  inflammation  of. 
Dura  Mater,  inflammation  of  sinuses  of,  54,  88. 
Dyspepsia  of  infants,  symptoms  of,  360. 

treatment,  when  dependent  on   debility, 

361. 
gastric  disorder,  362. 
use  of  alkalies  in,  363. 
strumous,  as  a  symptom  of  phthisis,  286. 


Dyspnoea,   nervuos,  in  course   of  bronchitis, 
189. 
hooping-cough,  254,  261,  262,  263. 
treatment  of,  272,  274. 
Dysuria  of  young  children,  425. 
treatment  of,  425. 

from  calculus  in  urethra ;  from  long  pre- 
puce, 425. 


E. 


Ear,  inflammation  of  internal,  86. 

symptoms  of,  86. 

diagnosis  from  inflammation  of  brain,  87. 

extending  to  brain,  85,  86. 

treatment,  86. 
Emetics,  in  treatment  of  croup,  224,  227,  238. 

caution  with  reference  to  their  use,  228. 
Emphysema,  its  association  with  pneumonia, 
178. 

relation  of  hooping-cough  to  its  produc- 
tion, 268. 
Encephalitis,   or  simple  inflammation  of  the 
brain,  58.t 

its  differences  from  hydrocephalus — cases 
illustrative  of,  82,  83. 

morbid  appearances  in,  84. 

its  occurrence  rare,  85. 

treatment  of,  85. 
Endocarditis,  idiopathic,  308. 

effects  of,  tend  to  increase — cases,  309. 

occasional  amelioration  in — cases,  310. 

see  Heart,  Diseases  of. 
Epilepsy,  136. 

rare  in  early  childhood,  137. 

its  causes,  137. 
Exanthemata,  general  characteristics  of,  443. 


F. 


Facial  Hemiplegia  in  new-born  infants,  146. 
Peeding,  Artificial,  of  Infants,  high  mortality 
from,  326. 
its  injurious  effects  explained,  328. 
morbid  appearances  produced  by,  330. 
rules  for,  when  necessary,  332. 
caution  as  to  occasional  unhealthiness  of 
cows'  milk,  334. 
Fevers   in   childhood,    chiefly  Exanthemata, 
443. 
Simple  fever,  same  in  child  and  in  adult, 
444. 
identical  with  Remittent  Pever,  444. 
see  Remittent  Pever. 


Gangrene  of  the  Lung,  179,  205. 
see  Lung,  gangrene  of. 
Mouth,  349. 

see  Stomatitis,  gangrenous. 
Gastric   Disorder,   diagnosis   of,   from  pneu- 
monia, 198. 
pleurisy,  210. 
Gastric  Disorder,  diagnosis  of,  from  remittent 

fever,  449. 
Gums,  lancing  of,  rules  for,  during  teething, 
341. 
caution  needed  in  cases  of  spasm  of  the 
glottis,   248. 


INDEX. 


481 


n. 


Haeniatemesis,  circumstances  under  which  it 
occurs,  367. 
illustrative  cases,  368. 
spurious,  370. 
Haemoptysis  rare  in  phthisis  of  children,  286. 

cases  of  fatal,  289. 
Haemorrhage    from    Umbilicus  in   new-born 

children,  373. 
Heart,  Diseases  of,  303. 
Table  of  33  cases  of,  317. 
frequency  in  childhood  underrated,  303. 
acute  rheumatism  most  frequent  cause  of, 

304. 
associated  with  scarlatina ;  with  pleurisy, 

305. 
idiopathic,  306. 

their  tendency  to  increase,  310. 
occasional  pauses  in  advance  of,  311. 
rarity  of  analmic  bruits,  313. 
congenital — cases  of,  314. 
Hectic,  rare  in  phthisis  of  children,  286. 
Hemiplegia,  facial  in  new-born  infants,  146. 
Hernia,  Strangulated,  in  infants,  379. 
Hip-joint  disease,  diagnosis  from  partial  palsy 

of  the  leg,  145. 
Hooping-cough,  essentially  a  disease  of  child- 
hood, 252,  266. 
symptoms  of — the  hoop,  253,  255,  256. 
catarrhal  stage,  254. 
varying  at  onset  of,  255. 
nervous  dyspnoea  in,  256,  261,  262,  263. 
at  its  acme,  256. 
nocturnal  exacerbations  of,  256. 
indications  of  amendment  and  deteriora- 
tion, 2o%. 
cough    often,  diminished   by  intercurrent 

febrile  affections,  259,  268. 
complications    of,   with    bronchitis    and 

pneumonia,  259. 
disorder  of  nervous  system,  260. 
congestion  of  brain,  42. 
convulsions,  31,  262. 

tubercular  hydrocephalus — case  illustra- 
tive of,  263. 
diarrhoea,  265. 

irritable  stomach  and  vomiting,  261,  266. 
measles  and  varicella,  266. 
duration  of,  267. 
its  catarrhal  stage,  254. 
recurrence  of,  268. 
causes  of ;  influence  of  sex  and  age,  (and 

note),  268. 
season  and  temperature,  269. 
.contagion,  270. 

deaths  from,  at  different  ages,  (note),  269. 
from  different  complications,  (note),  258. 
morbid  appearances  in,  (and  note.)  270. 
state  of  the  lungs,   Alderson's   observa- 
tions, (note,)  271. 
pneumo-gastric  nerves,  272. 
treatment  of,  of  first  stage,  273. 
second  stage;  use  of  hydrocyanic   acid, 

274. 
sedatives,  275. 
depletion,  counter-irritation  and  blisters, 

279. 
third  stage,  274. 

the  nervous  dyspnoea;  danger  of  over- 
treatment — case  in  illustration,  272, 
274. 

31 


Hooping-cough,  bronchitis  complicating,  274. 

decline  of,  275. 
Hydatids  of  Brain,  120. 

Hydrocephaloid  Disease,  Dr.  M.  Hall's  account 
of,  110. 

supervention   of,  in  course  of  diarrhoea, 
111. 

pneumonia,  and  consequent  on  cerebral 
congestion,  113. 

caution  against  mistaking  its  symptoms, 
114. 

rules   for  its  prevention   and  treatment, 
115. 
Hydrocephalus,  Acute,  or  scrofulous  inflamma- 
tion of  the  brain,  58. 

ages  at  which  it  occurs,  76,  (note)  77. 

predisposition  to,  in  phthisical  families, 
77. 

morbid  appearances  in,  two  kinds  of,  58. 

table  of  36  dissections  of,  (note)  64. 

at  base  of  brain,  59. 

granulations  of  the  membranes,  60. 

their  tubercular  nature,  61. 

state  of  cerebral  substance  in,  and  relation 
to  fluid  in  ventricles,  61. 

softening  not  due  to  imbibition  of  fluid,  63. 

result   of  inflammation ;   its   relation  to 
changes  in  lining  of  ventricles,  64. 

tubercular  deposits  in  brain  in,  64. 

complications  of,  65. 

symptoms  of  first  stage  of,  67. 

second,  67. 

third,  68. 

vary  in  different  cases,  70. 

approach  sometimes  very  gradual,  71,  75. 

three  stages  of,  not  always  distinct,  77. 

occasional  occurrence  of  diarrhoea  in,  80. 

diagnosis  of,  from  inflammation  of  inter- 
nal ear,  89. 

night  terrors,  135. 

remittent  fever,  72. 

remissions  in,  irregular,  73,  75. 

gastric  disorder,  73. 

pneumonia,  198. 

pleurisy,  209. 

prognosis  in,  very  unfavourable,  74. 

appearances  of  improvement  delusive,  74. 

caution  as  to  sleep  in,  75. 

duration  of,  76. 

treatment  of,  prophylaxis  of,  77. 

depletion  in,  79. 

purgatives  in,  79. 

use  of  mercurials,  and  application  of  cold 
in,  80. 

diet,  use  of  narcotics,  application  of  blis- 
ters in,  81. 

last  stage  of,  82. 
Chronic,    circumstances    under    which    it 
occurs,  89. 

occasional  result  of  cerebral  congestion. 
39. 

connected  with  malformation  of  the  brain, 
98,  101,  102,  103. 

external  and  internal,  98. 

internal,  symptoms  of,  98. 

changes  of  skull  in,  99. 

progress  and  termination  of,  100. 

age  at  which  it  comes  on,  101. 

post-mortem  appearances  in,  101. 

frequent  connection  with  inflammation- 
cases,  101,  103. 

sometimes  arrested,  rarely  cured,  104. 


482 


INDEX. 


Hydrocephalus,  chronic,  external,  its  various 
causes,  105. 
symptoms  and   those   of  internal  nearly 

coincident,  105. 
diagnosis  from  hypertrophy  of  brain,  113. 
treatment  of,  106. 

Golis's  plan  and  use  of  compression,  107. 
by  puncture,  108. 
Spurious,  110. 

see  Hydrocephaloid  Disease. 
Hydrocyanic  Acid  in  treatment  of  hooping- 
cough,  271. 
Hypertrophy  of  Brain,  101. 

see  Brain,  Hypertrophy  of. 


I. 


Icterus  Neonatorum,  371. 

see  Jaundice. 
Idiocy,   connection  of,  with   hypertrophy  of 

brain,  103. 
Induration  of  the  cellular  tissue,  symptoms  of, 
164. 
appearances  after  death,  165. 
connection  of,  with  collapse  of  the  lung, 

166. 
treatment  of,  166. 
Infants,  Artificial  Feeding,  of,  injurious;  high 
mortality  from,  326. 
injurious  action  of,  explained,  328. 
farinaceous  substances  unsuitable  for,  329. 
.  Atrophy  of,  causes  of,  various,  335. 
post-mortem  appearances  in,  330. 
Inoculation  of  small-pox,  comparative  advan- 
tages and  evils  of,  455. 
Intellect,  temporary  weakening  of,  after  long 

illness,  107. 
Intertrigo    in    course   of   chronic    diarrhoea, 

treatment  of,  401. 
Intestinal  Worms,  416. 

see  Worms. 
Intestines,  Softening  of,  366. 
Intussusception  of  Intestines,  symptoms   of, 
379. 
diagnosis  of,  380. 
treatment  of,  381. 
Inward  Fits,  meaning  of  the  term,  33. 


J. 


Jaundice,  of  New-born  Infants,  different 
opinions  concerning,  371. 

influence  of  cold  and  bad  air  in  causing  it, 
372. 

sometimes  depends  on  obstruction  or  mal- 
formation of  biliary  ducts,  372. 

treatment  of,  372. 

of  Children,  sometimes  associated  with 
head  symptoms,  373. 

treatment  of,  373. 


Kidneys,  Simple  Inflammation  of,  419. 
Inflammation  of,  with  Albuminuria,  419. 
as  sequela  of  scarlatina,  419. 
composition  of  urine  in,  420. 
post-mortem  appearances,  results  of  the 
microscope,  421. 


Kidneys,  Inflammation  of,  treatment  of,  422. 
Gravel  and  Calculus  in,  very   frequent  in 
children,  424. 
lithic    acid    very  frequent  in   new-born 

children,  425. 
formed  during  teething,  425. 
Fungoid  disease  of,  435. 


L. 


Laryngismus  Stridulus,  239. 

see  Spasm  of  the  Glottis. 
Laryngitis  Stridula,  237. 

see  Croup. 
Laryngitis,  Ulcerative,  218. 

see  Croup. 
Leeches,  rules  for  applying  to  the  head,  97. 

employment  of,  in  congestion  of  brain,  40. 
Leucorrhoea  of  young  children,  441. 

see  Vulva,  discharge s'from. 
Lithates,  formation  of,  in  new-born  children, 
425. 
during  dentition,  425. 
connection  of,  with  dyspepsia  and  rheu- 
matism, 425. 
treatment  of  excess  of,  425,  426. 
Liver,  hypertrophy  of,  431. 
hydatids  of,  432. 
fungoid  disease  of,  434. 
Lungs,  Elasticity  of,  150. 
Imperfect  Expansion  of,  150. 

conditions  under  which   it   occurs,  151, 

152. 
anatomical  characters,  and  effects  of  in- 
flation on  the  lung,  152. 
symptoms  of,  153. 
cases  illustrative  of,  154. 
diagnosis   of,   from   congenital  phthisis, 

155. 
treatment  of,  155. 
see  Lungs,  Collapse  of. 
Carnification  of,  158,  175. 
see  Lungs,  Collapse  of. 
Collapse  of,  erroneously  regarded  as  pneu- 
monia, 157. 
anatomical  characters  and  symptoms  of 

this  supposed  lobular  pneumonia,  158. 
effects  of  inflation  on  lung,  159. 
researches  of  Bailly  and  Legendre  on  it, 

159. 
cases  illustrative  of  its  occurrence,  160. 
occurs  from  similar  causes  in  adults  as  in 

children,  162. 
observations    of   its    occurrence  in    the 

aged,  163. 
its  supervention  in  course  of  bronchitis, 

175,  183. 
in  hooping-cough,  271. 
association  with  it  of  induration  of  the 
cellular  tissue,  165. 
Congestion  and  other  changes  of  substance 

of,  in  course  of  bronchitis,  175. 
Inflammation  of  substance  of,  177. 

see  Pneumonia. 
Abscess  of,  175,  178. 
Emphysema  of,  179. 
Acute  (Edema  of,  203. 
generally  succeeds  to  scarlatinal  dropsy — 

illustrative  cases,  204. 
post-mortem  appearances,  205. 
treatment  of,  205. 


INDEX. 


483 


Lungs,  Gangrene  of,  179. 

case  illustrative  of,  205. ' 
to  be  regarded  as  a  blood-disease,  207. 
symptoms  of,  207. 
treatment  of,  208. 
Tubercle  of,  table  of  81  cases  of,  (note),  280. 
miliary,    and    grey    granulations,    often 

exist  alone,  281. 
yellow  infiltration  frequent,  281. 
cavities  from,  rare,  282. 
small  cavities,  or  vacuoles,  282. 
frequent  affection   of   bronchial  glands, 

283. 
of  bronchial  glands,  characters  of,  283. 
sometimes  got  rid  of,  and  how,  284. 
perforation  of  bronchi,  <fcc,  from,  285. 


M. 


Measles  and  scarlatina,  mortality  from,  465. 

resemble  but  essentially  different,  465. 

essentially  a  disease  of  early  childhood, 
465. 

symptoms  of,  465. 

characters  of  the  eruption,  466. 

diagnosis  of,  from  scarlatina,  474. 

complicated  with   bronchitis   and  pneu- 
monia, 467. 

croup,  233. 

in  early  stage  of,  233. 

complicated    with    croup,    desquamative 
stage  of,  234. 

post-mortem  appearances  of,  234. 

relation  of,\to  hooping-cough,  467,  266. 

treatment  of\467. 

of  symptoms  of  affection  of  chest  in,  467. 

of  croup  in,  235,  237. 

cauterization  of  larynx  in,  236. 
Mehena,  367. 

see  Hasmatemesis. 
Meningitis,  Acute,  82. 

see  Encephalitis. 
Tubercular,  56. 

see  Hydrocephalus. 

of  Spinal  Cord — cases  illustrative  of,  128. 

post-mortem  appearances  in,  129. 

see  Spinal  Cord. 
Mercury  in  treatment  of  acute  hydrocephalus, 
77. 

pneumonia,  201. 

croup,  225,  229,  236. 

infantile  syphilis,  440. 
Microcephalus,  107. 
Milk,  human,  composition  of,  325,  332. 

and  of  animals  compared,  332. 

peculiar  adaptation  of,  to  nourishment  of 
child,  331. 

its  spontaneous  coagulation  in  the   sto- 
mach, 363. 

deterioration   of,  in  scrofulous  subjects,' 
Klencke's  remarks  on,  301. 

unhealthy,  chemical  and  microscopic  cha- 
racters of,  334. 

best  substitutes  for,  332. 

of  cow  occasionally  unhealthy,  333. 
Muguet,  336. 

see  Thrush. 
Mumps,  357. 


N. 


Narcotics,  in  treatment  of  acute  hydrocepha* 

lus,  81. 
Nervous  System,  diseases  of,  extremely  fre- 
quent in  early  life,  27. 

frequency  of,  accounted  for,  27. 

deaths  from,  at  different  ages,  (note),  31. 

and  from  other  causes,  (note),  143. 

symptoms  of,  28. 

difficulties  of  study  of,  28. 

disorders  of,  complicating  diarrhoea,  385, 
392. 

treatment  of,  397. 

influence  of  malaria  in  producing,  394. 
Nephritis,  simple,  418. 

albuminous,  419. 

see  Kidneys,  inflammation  of. 
Night  Terrors  of  children,  description  of  an 
attack  of,  133. 

not  indicative  of  primary  mischief  in  the 
brain — cases,  135. 

dependent  on  gastric  disorder,  136. 

treatment  of,  137. 
Noma,  347. 

see  Stomatitis,  ulcerative. 
Nurse,  statements  of,  not  to  be  undervalued, 
24. 


Odontitis  Infantum,  341. 

treatment  of,  342. 

see  Dentition. 

(Edema  of  Lungs,  203. 

see  Lungs,  oedema  of. 
Opium  in  treatment  of  hooping-cough,  270. 

and  Antimony  in  head  symptoms  of  re- 
mittent fever,  452. 
Otitis,  86. 

see  Ear,  inflammation  of. 
Otorrhcea,  importance  of  head  symptoms  in, 
85,  87. 

chronic,  treatment  of,  88. 


P. 


Paralysis,  import  of,  less  serious  in  child  than 
in  adult,  139. 

sometimes  congenital,  139. 

of  portio  dura  from  injury  in  birth,  146. 

most  frequent  during  period  of  dentition, 
141. 

results  of  twenty  cases,  and  tabular  view 
of,  142. 

recovery  from,  uncertain,  144. 

diagnosis  of,  144. 

treatment  of,  145. 

electricity  in,  146. 
Percussion,  general  rules  for,  20. 
Pericarditis,  usually  connected  with  rheuma- 
tism, 304. 

sometimes    associated    with    pleurisy  — 
cases  of,  305. 

idiopathic — cases  of,  306,  315. 

not  always  discovered  during  life,  308. 
Peritonitis,  in  the  foetus  sometimes  connected 
with  syphilis,  403. 

in  early  infancy,  403. 


484 


INDEX. 


Peritonitis,   sometimes   acute   and   epidemic, 
403. 
in  childhood,  acute,  idiopathic,  rare,  401, 

404. 
symptoms,  case  illustrating,  404. 
discharge  of  pus  through  abdominal  walls 

in,  89,  406. 
secondary  to  scarlatina,  407. 
to  inflammation  of  caecum — case  of,  407. 
treatment  of,  408. 
chronic,  usually  tubercular,  409. 
morbid  appearances  in,  409. 
symptoms  and  general  course  of,  410. 
varieties  in  its  onset  and  course,  412. 
relations  of,  to  Tabes  Mesenterica,  412. 
See  Tabes  Mesenterica. 
Phlebitis,  of  Sinuses  of  Dura  Mater,  88. 

Umbilical  Vein  not  a  cause  of  trismus,  132. 
Phthisis,  differences  between  disease  in  child 

and  adult,  278. 
tables  illustrative  of  various  peculiarities, 

(note)  280,  281. 
affects  different  organs  in  child;  illustra- 
tive table,  279. 
assumes  different  forms,  280. 
owing  in  part  to  its  rapid  progress,  281. 
symptoms  of,  their  peculiarities,  285,293. 
auscultatory,  289,  294. 
congenital,  155. 
in  early  infancy,  288. 
of  bronchial  phthisis,  287,  293. 
spasmodic  cough  in,  239. 
auscultatory,  290,  293. 
diagnosis  of,  from  worms  and  remittent 

fever,  286,  450. 
tuberculous  pneumonia,  295. 
import  of  frequent  attacks  of  catarrh,  171. 
duration  of,  298. 
rapid  course  of — case,  294. 
chronic  course  of — cases,  298. 
prognosis  of,  more  hopeful  in  child  than 

in  adult,  302. 
in  bronchial  phthisis — case  of  recovery 

from,  288. 
death  from,  various  modes  of,  299. 
supervention  of  hydrocephalus  in,  71,  77. 
head  symptoms — case,  300. 
treatment  of,  prophylaxis,  301. 
treatment  of,  remedies  in ;  cod-liver  oil, 

Ac,  302. 
Pia  Mater,  its  changes  in  acute  hydrocephalus, 

60. 
Pleurisy,  acute  idiopathic,  very  rare  in  early 

childhood,  208. 
post  mortem  appearances  of,  208. 
complicated  with  pericarditis,  306. 
symptoms  and  physical  signs   of,  some 

peculiarities  in,  209. 
diagnosis  of,  from  head  affection,  210. 
affections  of  the  abdomen,  210. 
pneumonia;  its  difficulty,  197,  214. 
treatment  of,  212. 
secondary  and  chronic,  212. 
chronic,  a  sequela  of  scarlatina,  213. 
Pneumonia,  causes  and  frequency  of;  illustra- 
tive table,  180. 
post-mortem  appearances  in,  177. 
termination  in  abscess,  178. 
gangrene,  179. 

association  with  emphysema,  179. 
Idiopathic,  symptoms  of  first  stage  of,  192. 
second,  194. 


Pneumonia,  Idiopathic,  third,  194. 

results  of,  death  in  second  stage,   occa- 
sional, 194. 

imperfect  recovery  from  third  stage,  occa- 
sional, 195. 

auscultatory  signs  of,  196. 

recurrence  of,  180. 

diagnosis  of,  from  pleurisy,  197,  228. 
•hydrocephalus,  198. 

head  symptoms  in,  113. 

gastric  disorder,  198. 

dentition,  199. 

treatment  of,  depletion  in,  200. 

tartar  emetic  in,  201. 

mercurials  in,  201. 

stimulants  and  blisters  in,  202. 
Secondary  to  bronchitis;  a  point  of  differ- 
ence from  disease  in  adult,  171. 

symptoms  of,  196. 

various  diseases,  181. 

measles,  468. 

hooping-cough,  279. 
Lobular,  cases  properly  so  called,  175. 

description  under  the  name  of  collapse  of 
the  lung,  158. 

Tuberculous,  characteristics  of,  295. 
Psoas  Abscess,  characters  of  tumours  formed 

by,  435. 
Puerile  breathing  not  heard  in  early  infancy, 

and  why,  149. 
Pulse,  great  variations  in  its  frequency,  19. 

frequency  of,  in  infancy  and  childhood, 
150. 

and   of   respiration,   diminished    during 
sleep,  24. 

and  that  of  respiration  to  be  compared,  in 
sick  children,  19. 

peculiarities  in  hydrocephalus,  67,  68,  72, 
77. 
Purgatives,  remarks  on  different  kinds  of,  247. 

in  congestion  of  brain,  41. 

in  acute  hydrocephalus,  79. 


P. 


Rectum,  Imperforate,  three  varieties  of,  374. 

its  rarity;  its  symptoms,  374. 

circumstances  modifying  prognosis,  376. 

various  operations  for  its  cure,  378. 
Remittent  Pever,  identity  with  simple  fever 
in  adult,  444. 

post-mortem  appearances  of,  444. 

symptoms  of  milder  form  of,  445. 

appearance  of  eruption  in,  446. 

severer  form  of,  446. 

eruption  in,  447. 

symptoms  of  severer  form  of,  delirium  in, 
448,  450. 

death  rare  in ;  causes  of,  when  it  occurs, 
448. 

diagnosis  of,  from  simple  gastric  disorder, 
449. 

acute  tubercular  disease,  286,  449. 

hydrocephalus,  72. 

occasional  supervention  of  cerebral  mis- 
chief in,  449. 

treatment  of,  450. 

the  abdominal  symptoms  of,  457. 

cerebral  disturbance  in,  use  of  antimony 
and  opium,  452. 

depletion  in,  453. 


INDEX. 


485 


Remittent  Fever,  diet  in,  453. 

stimulants  in,  453. 
Rheumatism,    Acute,    followed     even    when 

slight  hy  heart  disease,  304. 
Chronic,  its   connection   with   excess   of 

lithates  in  the  urine,  425. 
Respiration,  peculiarities  of,  in  early  life,  148, 

160. 
its  frequency  in  infancy  and  childhood, 

159. 
feebleness  of  inspiratory  power,  160. 
similarity  of  its  characters  in  infancy  and 

old  age,  163. 
frequency   of,   and  of  pulse,  diminished 

during  sleep,  24. 
its  general  characters  to   be   noticed  in 

sick  children,  21. 
its   frequency,  and  that  of  pulse,  to  be 

compared  in  sick  children,  19. 
peculiarities  of,  in  cerebral  disease,  30. 
organs  of,  death  from  diseases  of,  and  from 

other  causes,  compared,  (note)  147. 
susceptibility  of  their  mucous  membrane, 

166,  170. 
this    susceptibility  less    at    birth    than 

afterwards,  ]  67. 
inflammatory  affections  of,  167. 
Retro-pharyngeal  abscess,  its  symptoms,  and 

means  of  diagnosis  of,  174. 
Re- vaccination,  reasons  in  favour  of,  462. 
Rickets,  connection   of,  with  hypertrophy  of 

brain,  102, 103. 


Scarlatina,  varieties  of,  469. 
Simplex,  symptoms  of,  469. 
characters  a,nd  progress  of  the  eruption, 

469.  \ 

Anginosa,  symptoms  of,  affection  of  throat 

in,  470. 
Maligna,  symptoms  of,  case  illustrative  of, 

471. 
affection  of  throat  and  parotids  in,  472. 
various  complications  of,  472. 
supervention  of  endocarditis  in  course  of, 

306. 
post-mortem  appearances  in,  473. 
diagnosis  of,  from  measles,  476. 
sequelae   of  —  retro-pharyngeal  abscess, 

474. 
dropsy,  419. 
exciting  causes  of,  422. 
symptoms  of,  419. 
composition  of  urine  in,  420,  423. 
state  of  kidneys  in,  421. 
sources  of  danger  in,  422. 
occasionally  arises   from   mere   debility, 

423. 
treatment  of,  475. 
caution  as  to  depletion  in  head  affections 

in,  476. 
the  coryza  and  affection  of  throat  in,  476. 
dropsy  in,  422. 
depletion  in,  422. 
use  of  tartar  emetic  in,  423. 
Sedatives  in  treatment  of  hooping-cough,  272. 
Sleep,   frequency    of   pulse    and    respiration 

diminished  during  it,  24. 
its  characters  to  be  observed  in  sick  chil- 
dren, 19. 
caution  concerning,  in  hydrocephalus,  75. 


Small-pox,  influence  of  inoculation  and  of  vac- 
cination on,  456. 

mortality  from,  456. 

symptoms  of,  and  diagnosis  from  other 
eruptive  fevers,  457. 

symptoms  of,   progress   of  the  eruption, 
458. 

peculiarities  of  the  confluent  form,  458. 

secondary  fever,  its  dangers,  458. 

treatment  of,  459. 

the  secondary  fever  of,  460. 

local   symptoms — prevention   of   pitting, 
461. 

after  Vaccination,  its  usually  mild  cha- 
racter, 462. 

peculiarities  of  its  course  and  symptoms, 
463. 
Spasm  of  the  Glottis,  239. 

symptoms  of,  240,  242. 

carpopedal  contractions  in,  241. 

import  of,  242. 

circumstances  under  which  it  occurs,  243. 

case   illustrative   of  its  connection  with 
enlarged  thymus  gland,  244. 

treatment  of,  246. 

caution  as  to  lancing  the  gums  in,  247. 

case  illustrative  of  occasional  necessity 
for  depletion,  248. 

caution  as  to  sudden  exposure  to  air,  249. 

the  paroxysm,  249. 

proposed,  when  dependent   on   enlarged 
thymus,  249. 
Speech,  temporary  loss  of  power  of,  after  long 

illness,  107. 
Spinal  cord,  predominance  of,  in  early  life,  31. 

special  obscurity   of  disease   of,   in   the 
child,  123. 

Dr.  Weber's  observations  on  vascularity 
of,  131. 

irritation  and  congestion  of — cases,  124. 

membranes  of,  usually  involved  in,  sim- 
ple encephalitis,  84. 

inflammation  of  its  membranes  sometimes 
epidemic,  125. 

cases  illustrative  of  inflammation  of,  125. 

acute  inflammation  of  substance  of,  128. 

chronic  inflammation  of  substance  of,  129. 

softening    of,   generally   connected  with 
disease  of  vertebrae,  129. 

remarkable  case  of,  without  disease  of  the 
bones,  130. 
Spleen,  enlargement  of,  435. 
Stimulants,  use  of,  in  treatment  of  diarrhoea. 

398. 
Stomach,  peculiarities  of  form  of,  in  infancy, 
324. 

changes  in  form  of,  with  advancing  years, 
326. 
Softening  of,  different  opinions  concerning, 
365. 

characters  of,  365. 

alleged  influence  of  mode  of  death  on, 
366. 

its    frequency  in  infancy,  theories    ac- 
counting for,  367. 
Stomatitis,  three  varieties  of,  344. 
Follicular,  symptoms  and  course  of,  345. 

treatment  of,  341,  346. 
Ulcerative,  or  Noma,  symptoms  and  course 
of,  346. 

tendency   to    pass    into    gangrene  very 
slight,  347. 


486 


INDEX, 


Stomatitis,  Ulcerative,  treatment  of,  343,  348. 
Gangrenous,  fatality  of,  348. 

its  connection  with  blood  diseases,  349. 

does   not   depend   on   administration    of 
mercury,  354. 

point  of  departure  of  the  gangrene,  349. 

symptoms  and  cause  of,  350. 

morbid  appearances  in,  351. 

treatment;  importance  of  cauterization, 
352. 
Sulphate  of  Magnesia,  use  of  small  doses  of, 

in  diarrhoea,  394. 
Syphilis,  Infantile,  dependent  on  congenital 
taint,  436. 

relation  of,  to  foetal  and  infantile  peri- 
tonitis, 403. 

symptoms  of,  437. 

coryza  sometimes  the  only  one,  438. 

rarity  of  affection  of  bones,  438. 

syphilitic  cachexia,  440. 

relapses  and  tertiary  symptoms,  440. 
treatment  of,  440. 

local  applications  in,  441. 


Tabes   Mesenterica,  relation  of,  to  tubercular 
peritonitis,  412. 
anatomical  characters  of,  413. 
symptoms  not  pathognomonic  of,  414. 
treatment  of,  and  of  tubercular  peritonitis, 
414. 
Temperature,  in  infancy  and  chilhood,  149. 
pneumonia,  193. 
remittent  fever,  20. 
scarlatina,  470. 
Thirst,  indications  of,  in  the  infant,  24. 
Thrush,    etymology  of   the  word    uncertain, 
(note,)  356. 
ifcs  characters  described,  356. 
disorder  of  health  attending  it,  357. 
opinions  as  to  intimate  nature  of  the  de- 
posit, 357. 
treatment  of,  358. 
Thymic  Asthma,  244. 

see  Spasm  of  the  Glottis. 
Tongue,  in  infants,  how  to  examine  the,  22. 
Tonsils,  Inflammation  of,  355. 
Hypertrophy  of,  its  symptoms,  355. 
its  influence  on  the  form  of  the  mouth, 

and  chest,  356. 

its  treatment,  357. 

Tracheotomy,  in  croup,  228. 

difference    of  results    in    England    and 

France,  228. 
objections  to  performance  of,  229. 
remarks  of  M.  Trousseau  on,  230. 
reasons  for  not  rejecting,  231. 
Trismus,  infantile,  symptoms  of,  131. 
post-mortem  appearances  in,  131. 
opinions  as  to  its  cause,  132. 
modes  of  prevention,  and  of  treatment, 
133. 


Tubercle  of  Brain,  115. 

see  Brain,  Tubercle  of. 
Mesenteric  Glands,  412. 

see  Tabes  Mesenterica. 
Tubercular  Peritonitis,  409. 

see  Peritonitis,  chronic. 
Tumors,  Abdominal,  430. 

see  Abdominal  Tumors. 

U. 

Umbilicus,  discharge  of  pus  from,  in  perito- 
nitis, 89. 
haemorrhage  from,  in  new-born  children, 
373. 
Urea,  excess  of,  426,  427. 
Urine,  incontinence  of — causes,  428. 
treatment,  429. 


V. 


Vaccination,    drawbacks  from  its  universal 
success,  456. 
great  benefits  of,  462. 
adoption    of,    followed    by    increase    of 
measles  and  scarlatina,  465. 
Varicella,  463. 

relation  of,  to  hooping-cough,  271. 
see  Chicken-pox. 
Variola,  456. 

see  Small- pox. 
Vertebrae,  disease   of  the  cervical,  extending 
to  brain,  85. 
affection  of  spinal  cord  in  cases  of,  129. 
Vomiting,  in  infants,  its  frequency  accounted 
for,  358. 
treatment  of,  359. 
as  a  sign  of  dyspepsia,  360. 
in  course  of  diarrhoea,  397. 
treatment  of,  388. 
important  as  a  sign  of  cerebral  disease, 

30,  38. 
in  first  stage  of  hydrocephalus,  67. 
persistent,  of  great  importance  as  a  sign 

of  hydrocephalus,  73. 
in  hooping-cough,  261,  266. 
Vulva,  discharges  from,  441. 

circumstances  under  which   they  occur, 

442. 
treatment  of,  442. 


W. 


Waterstroke,  meaning  of  the  term,  77. 

case  of,  83. 
Whytt,  Dr.  his  observations  on  Acute  Hydro- 
cephalus, 57. 
Worms,  intestinal,  five  varieties  of,  417. 

symptoms  of,  418. 

convulsions  from,  419. 

treatment  of,  418. 

of  Blood,  369. 

see  Hsematemesis. 


INDEX  TO  FORMULA 


NO.^  PAGE. 

Acid  Mixture  for  hooping-cough    xviii 277 

-ffithereal  stimulant  for  fever  xxxiv 454 

Alterative,  saline    xxvi 364 

tonic xxxiii 415 

Alum  Mixture  for  hooping-cough  xvii 276 

Antimonial,  nauseating    . xiii 223 

Aperient  v. 77 

aloetic xxiii 362 

■ febrifuge » i.           42 

saline  vi.           77 

Astringent   xxyii 395 

■            aromatic,  opiate    xxix 391 

gallic  acid,  opiate xxx 399 

lead  and  opium xxxi 400 

sulphate  of  iron  and  opium xxxii 400 

Cinchona  and  hydrocyanic  acid  mixture xx 277 

Cough  Mixtures viiii.  ix.  x 169,171 

Decoction  Blanche 45 

Demulcent   xxi 343 

Expectorant,  stimulating xii.          190 

Febrifuge,  aperient   i.             42 

calmant ii.^          43 

Hooping-cough,  alum  mixture  for xvii.         276 

acid  mixture  for  xviii 277 

Hydrocyanic  acid , xiv.  xv 271 

with  bark   xx.          277 

Iron,  expectorant  mixture  for  chronic  bronchitis  or  hooping-cough         xix 277 

Liniment,  stimulating,  for  the  chest xi.          190 

Oleaginous,  opiate,  for  diarrhoea xxviii 396 

Opiate  powder    xvi 272 

Saline,  antimonial xiii.         223 

Sedative,  hydrocyanic  acid xiv.  xv 271 

opiate  powder xvi. 272 

Stimulant  aethereal xxxiv 454 

expectorant xii. 190 

Tan-bath  106 

Tonic,  alterative xxxiii 415 

aperient .-. vii.           77 

astringent  iii.           45 

chalybeate  iv.           45 

■ — alum  and  sulphuric  acid xvii.         276 

chalybeate,  expectorant  xix.          277 

cinchona,  and  hydrocyanic  acid xx.          277 

hydrochloric  acid xviii 277 

vegetable,  alkaline    xxiv 363 

with  mineral  acids xxii.  xxv.     ...     361,364 


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current  information  of  the  day,  while  the  "  Library  Department"  is  devoted  to  presenting  stand- 
ard works  on  various  branches  of  medicine.     Within  a  few  years,  subscribers  have  thus  received, 
without  expense,  the  following  works  which  have  passed  through  its  columns : — 
WATSON'S  LECTURES  ON  THE  PRACTICE  OF  PHYSIC. 
BRODIE'S  CLINICAL  LECTURES  ON  SURGERY. 

TODD  AND  BOWMAN'S  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN. 
WEST'S  LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 
MALGAIGNE'S  OPERATIVE  SURGERY,  with  wood-cuts. 
SIMON'S  LECTURES  ON  GENERAL  PATHOLOGY. 
BENNETT  ON  PULMONARY  TUBERCULOSIS,  with  wood-cuts, 
WEST  ON  ULCERATION  OF  THE  OS  UTERI,  and 

BROWN  ON  THE  SURGICAL  DISEASES  OF  FEMALES,  with  wood-cuts. 
WEST  ON  DISEASES  OF  WOMEN,  Part  I. 

While  in  the  number  for  January,  1858,  is  commenced  a  new  and  highly  important  work, 

HABERSHON  ON   DISEASES  OF  THE  ALIMENTARY  CANAL. 

It  will  be  seen  that  this  treatise  covers  the  whole  ground  of  affections  of  the  Digestive  Organs, 
which  furnish  so  very  large  a  portion  of  the  daily  practice  of  the  physician.  The  author's  position 
in  Guy's  Hospital,  and  the  fact  that  the  work  has  only  just  appeared  in  London,  are  sufficient  guar- 
antee that  it  is  up  to  the  hour,  and  presents  the  most  advanced  condition  of  this  department  of  medi- 
cal science,  while  its  thorough  practical  character  is  manifested  by  the  great  number  of  cases  on 
which  it  is  founded,  no  less  than  one  hundred  and  sixty-three  being  carefully  analyzed  in  all  their 
details,  throughout  its  pages.  It  is  therefore  hoped  that  it  will  be  found  to  fully  maintain  the  valu- 
able practical  character  of  the  works  heretofore  presented  to  subscribers  through  this  medium. 

It  will  thus  be  seen  that  for  the  small  sum  of  FIVE  DOLLARS,  paid  in  advance,  the  subscriber 
will  obtain  a  Quarterly  and  a  Monthly  periodical, 

EMBRACING  NEARLY  SIXTEEN  HUNDRED  LARGE  OCTAVO  PAGES, 

mailed  to  any  part  of  the  United  States,  free  of  postage. 

These  very  favorable  terms  are  now  presented  by  the  publishers  with  the  view  of  removing  all 
difficulties  and  objections  to  a  full  and  extended  circulation  of  the  Medical  Journal  to  the  office  of 
every  member  of  the  profession  throughout  the  United  States.  The  rapid  extension  of  mail  facili- 
ties will  now  place  the  numbers  before  subscribers  with  a  certainty  and  dispatch  not  heretofore 
attainable ;  while  by  the  system  now  proposed,  every  subscriber  throughout  the  Union  is  placed 
upon  an  equal  footing,  at  the  very  reasonable  price  of  Five  Dollars  for  two  periodicals,  without 
further  expense. 

Those  subscribers  who  do  not  pay  in  advance  will  bear  in  mind  that  their  subscription  of  Five 
Dollars  will  entitle  them  to  the  Journal  only,  without  the  News,  and  that  they  will  be  at  the  expense 
of  their  own  postage  on  the  receipt  of  each  number.  The  advantage  of  a  remittance  when  order- 
ing the  Journal  will  thus  be  apparent. 

As  the  Medical  News  and  Library  is  in  no  case  sent  without  advance  payment,  its  subscribers 
will  always  receive  it  free  of  postage. 

Remittances  of  subscriptions  can  be  mailed  at  our  risk,  when  a  certificate  is  taken  from  the  Post- 
master that  the  money  is  duly  inclosed  and  forwarded. 

Address  BLANCHARD  &  LEA,  Philadelphia. 


AND    SCIENTIFIC    PUBLICATIONS. 


ALLEN    (J.    M.),    M.  D., 
-  Professor  of  Anatomy  in  the  Pennsylvania  Medical  College,  &c. 

THE  PRACTICAL  ANATOMIST;  or,  The  Student's  Guide  in  the  Dissecting. 
ROOM.  With  266  illustrations.  In  one  handsome  royal  12mo.  volume,  of  over  600  pages,  lea- 
ther.    $2  25.     (Just  Issued.) 

In  the  arrangement  of  this  work,  the  author  has  endeavored  to  present  a  complete  and  thorough 
course  of  dissections  in  a  clearer  and  more  available  form  for  practical  use,  than  has  as  yet  been 
accomplished.  The  chapters  follow  each  other  in  the  order  in  which  dissections  are  usually  con- 
ducted in  this  country,  and  as  each  region  is  taken  up,  every  detail  regarding  it  is  fully  described 
and  illustrated,  so  that  the  student  is  not  interrupted  in  his  labors,  by  the  necessity  of  referring  from 
one  portion  of  the  volume  to  another. 


However  valuable  may  be  the  "  Dissector's 
Guides"  which  we,  of  late,  have  had  occasion  to 
notice,  we  feel  confident  that  the  work  of  Dr.  Allen 
is  superior  to  any  of  them.  We  believe  with  the 
author,  that  none  is  so  fully  illustrated  as  this,  and 
the  arrangement  of  the  work  is  such  as  to  facilitate 
the  labors  of  the  student  in  acquiring  a  thorough 
practical  knowledge  of  Anatomy.  We  most  cordi- 
ally recommend  it  to  their  attention. — Western  Lan- 
cet, Dec.  1856. 

We  believe  it  to  be  one  of  the  most  useful  works 
upon  the  subject  ever  written.  It  is  handsomely 
illustrated,  well  printed,  and  will  be  found  of  con- 
venient size  for  use  in  the  dissecting-room. — Med. 
Examiner,  Dec.  1856. 


From  Prof.  J.  S.  Davis,  University  of  Va. 

I  am  not  acquainted  with  any  work  that  attains  so 
fully  the  object  which  it  proposes. 

From  C.  P.  Fanner,  M.  P.,  Demonstrator,   Uni- 
versity of  Michigan. 

I  have  examined  the  work  briefly,  but  even  this 
examination  has  convinced  me  that  it  is  an  excellent 
guide  for  the  Dissector.  Its  illustrations  are  beau- 
tiful, and  more  than  I  have  seen  in  a  work  of  this 
kind.  I  shall  take  great  pleasure  in  recommending 
it  to  my  classes  as  the  text-book  of  the  dissecting- 
room. 


ANALYTICAL    COMPENDIUM 
OF  MEDIQAL  SCIENCE,  containing  Anatomy,  Physiology,  Surgery,  Midwifery, 
Chemistry,  Materia  Medica,  Therapeutics,  and  Practice  of  Medicine.    By  John  Neill,  M.  D., 
and  F.  G.  Smith,  M.  D.      New  and  enlarged  edition,  one  thick  volume  royal  l2mo.  of  over 
1000  pages,  with  374  illustrations.    EF*  See  Neill,  p.  24. 


ABEL  (F.   A.),    F.  C.S.    AND    C.    L.    BLOXAM. 
HANDBOOK  OF  CHEMISTRY,  Theoretical,  Practical,  and  Technical  j  with  a 

Recommendatory  Preface  by  Dr.  Hofmann.    In  one  large  octavo  volume,  extra  cloth,  of  662 
pages,  with  illustrations.    $3  25. 


> 


ASHWELL    (SAMUEL),    M.D., 

bstetric  Physician  and  Lecturer  to  Guy's  Hospital,  London. 


A  PRACTICAL  TREATISE  ON  THE  DISEASES  PECULIAR  TO  WOMEN. 

Illustrated  by  Cases  derived  from  Hospital  and  Private  Practice.  Third  American,  from  the  Third 
and  revised  London  edition.    In  one  octavo  volume,  extra  cloth,  of  528  pages.     $3  00. 
The  most  useful  practical  work  on  the  subject  in  I      The  most  able,  and  certainly  the  most  standard 
the  English  language.  —  Boston  Med.  and  Surg,    and  practical,  work  on  female  diseases  that  we  have 
Journal.  |  yet  seen. — Medico-Chirurgical  Review. 


ARNOTT   (NEILL),  M.  D. 
ELEMENTS    OF    PHYSICS;    or  Natural  Philosophy,  General  and  Medical. 

Written  for  universal  use,  in  plain  or  non-technical  language.  A  new  edition,  by  Isaac  Hays, 
M.  D.  Complete  in  one  octavo  volume,  leather,  of  484  pages,  with  about  two  hundred  illustra- 
tions.   $2  50.  

BUDD  (GEORGE),  M.  D.,  F.  R.  S., 

Professor  of  Medicine  in  King's  College,  London. 

ON  DISEASES   OF  THE  LIVER.      Third  American,  from   the  third   and 

enlarged  London  edition.  In  one  very  handsome  octavo  volume,  extra  cloth,  with  four  beauti- 
fully colored  plates,  and  numerous  wood-cuts.    pp.  500.     $3  00.     (Now  Ready.} 


Has  fairly  established  for  itself  a  place  among  the 
olassical  medical  literature  of  England.— British 
and  Foreign  Medico-Chir.  Review,  July,  1857. 

Dr.  Budd's  Treatise  on  Diseases  of  the  Liver  is 
now  a  standard  work  in  Medical  literature,  and  dur- 
ing the  intervals  which  have  elapsed  between  the 
successive  editions,  the  author  has  incorporated  into 
the  text  the  most  striking  novelties  which  have  cha- 
racterized the  recent  progress  of  hepatic  physiology 
and  pathology;  so  that  although  the  size  of  the  book 


$3  00. 

is  not  perceptibly  changed,  the  history  of  liver  dis- 
eases is  made  more  complete,  and  is  kept  upon  a  level 
with  the  progress  of  modern  science.    It  is  the  best 

work  on  Diseases  of  the  Liver  in  any  language. 

London  Med.  Times  and  Gazette,  June  27,  1357. 

This  work,  now  the  standard  book  of  reference  on 
the  diseases  of  which  it  treats,  has  been  carefully 
revised,  and  many  new  illustrations  of  the  views  of 
the  learned  author  added  in  the  present  edition. — 
Dublin  Quarterly  Journal,  Aug.  1857. 


BY  THE  SAME  AUTHOR. 


ON  THE   ORGANIC  DISEASES  AND  FUNCTIONAL  DISORDERS  OF 

THE  STOMACH.    In  one  neat  octavo  volume,  extra  cloth.    $1  50. 


From  the  high  position  occupied  by  Dr.  Budd  as 
a  teacher,  a  writer,  and  a  practitioner,  it  is  almost 
needless  to  state  that  the  present  book  may  be  con- 
sulted with  great  advantage.  It  is  written  in  an  easy 


style,  the  subjects  are  well  arranged,  and  the  practi- 
cal precepts,  both  of  diagnosis  and  treatment,  denote 
the  character  of  a  thoughtful  and  experienced  phy- 
sician.— London  Med.  Times  and  Gazette. 


BLANCHARD   &    LEA'S   MEDICAL 


BROWN    (ISAAC    BAKER), 

Surgeon- Accoucheur  to  St.  Mary's  Hospital,  &c.  4 

ON  SOME  DISEASES  OF  WOMEN  ADMITTING  OF  SURGICAL  TREAT- 
MENT.   With  handsome  illustrations.    One  vol.  8vo.,  extra  cloth,  pp  276.    $160. 
Mr.  Brown  has  earned  for  himself  a  high  reputa- 
tion in  the  operative  treatment  of  sundry  diseases 
and  injuries  to  which  females  are  peculiarly  subject 


We  can  truly  say  of  his  work  that  it  is  an  important 
addition  to  obstetrical  literature.  The  operative 
suggestions  and  contrivances  which  Mr.  Brown  de- 
scribes, exhibit  much  practical  sagacity  and  skill, 


and  merit  the  careful  attention  of  every   surgeon- 
accoucheur. — Association  Journal. 

We  have  no  hesitation  in  recommending  this  book 
to  the  careful  attention  of  all  surgeons  who  make 
female  complaints  a  part  of  their  study  and  practice. 
— Dublin  Quarterly  Journal. 


BENNETT   (J.    HUGHES),    M.P.,    F.  R.  S.  E., 

Professor  of  Clinical  Medicine  in  the  University  of  Edinburgh,  &c. 

THE  PATHOLOGY  AND  TREATMENT  OF  PULMONARY  TUBERCU- 

LOSIS,  and  on  the  Local  Medication  of  Pharyngeal  and  Laryngeal  Diseases  frequently  mistaken 
for  or  associated  with.  Phthisis.     One  vol.  8vo., extra  cloth,  with  wood-cuts.    pp.  130.     $1  25. 


BENNETT   (HENRY),  M.  D. 
A  PRACTICAL   TREATISE    ON  INFLAMMATION  OF  THE  UTERUS, 

ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Disease.     Fourth 
American,  from  the  third  and  revised  London  edition.     To  which  is  added  (July,  1856),  a  Review 
of  the  Present  State  of  Uterine  Pathology.     In  one  neat  octavo  volume,  extra  cloth,  of 
500  pages,  with  wood-cuts.     $2  00      Also,  the  "Review,"  for  sale  separate.     Price  50  cents. 
The  addition  of  the  "  Review"  presents  the  recent  aspects  of  the  questions  discussed  in  this 

well-known  work.  $. 

This  edition  has  been  carefully  revised  and  altered,  |      When,  a  few  years  back,  the  first  edition  of  the 

and  various  additions  have  been  made,  which  render  j  present  work  was  published,  the  subject  was  oneal- 


it  more  complete,  and,  if  possible,  more  worthy  of 
the  high  appreciation  in  which  it  is  held  by  the 
medical  profession  throughout  the  world.  A  copy 
should  be  in  the  possession  of  every  physician. — 
Charleston  Med.  Journal  and  Review. 

We  are  firmly  of  opinion  that  in  proportion  as  a 
knowledge  of  uterine  diseases  becomes  more  appre- 
ciated, this  work  will  be  proportionably  established 
as  a  text-book  in  the  profession. — The  Lancet. 


most  entirely  unknown  to  the  obstetrical  celebrities 
of  the  day  ;  and  even  now  we  have  reason  to  know 
that  the  bulk  of  the  profession  are  not  fully  alive  to 
the  importance  and  frequency  of  the  disease  of  which 
it  takes  cognizance.  The  present  edition  is  so  much 
enlarged,  altered,  and  improved,  that  it  can  scarcely 
be  considered  the  same  work. — Dr.  Ranking' s  Ab- 
stract. 


BIRD  (GOLDING),  A.  M.,  M .  D.,  &c. 
URINARY     DEPOSITS:     THEIR     DIAGNOSIS,    PATHOLOGY,    AND 

THERAPEUTICAL  INDICATIONS.    A  new  and  enlarged  American,  from  a  late  improved 
London  edition.  With  over  sixty  illustrations.   In  one  royal  12mo.  vol,  extra  cloth,  pp.372.  $130. 

extension  and  satisfactory  employment  of  our  thera- 


It  can  scarcely  be  necessary  for  us  to  say  anything 
of  the  merits  of  this  well-known  Treatise,  which  so 
admirably  brings  into  practical  application  the  re- 
sults of  those  microscopical  and  chemical  researches 
regarding  the  physiology  and  pathology  of  the  uri- 
nary secretion,  which  have  contributed  so  much  to 
the  increase  of  our  diagnostic  powers,  and  to  the 


peutic  resources.  In  the  preparation  of  this  new 
edition  of  his  work,  it  is  obvious  that  Dr.  Golding 
Bird  has  spared  no  pains  to  render  it  a  faithful  repre- 
sentation of  the  present  state  of  scientific  knowledge 
on  thesubject  it  embraces.—  The  British  and  Foreign 
Medico-C hirurgical  Review. 


BY   THE   SAME    AUTHOR. 


ELEMENTS  OF  NATURAL  PHILOSOPHY;   being  an  Experimental  Intro- 

duction  to  the  Physical  Sciences.     Illustrated  with  nearly  four  hundred  wood-cuts.     From  the 
third  London  edition.    In  one  neat  volume,  royal  12mo.,  extra  cloth,    pp.  402.    $1  25. 


BOWMAN  (JOHN   E.),  M.D. 
PRACTICAL   HANDBOOK   OF   MEDICAL   CHEMISTRY.     Second  Ame- 
rican, from  the  third  and  revised  English  Edition.    In  one  neat  volume,  royal  12mo.,  extra  cloth, 
with  numerous  illustrations,    pp.  288.     $1  25. 

BY  THE  SAME  AUTHOR. 

INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING  ANA- 
LYSIS. Second  American,  from  the  second  and  revised  London  edition.  With  numerous  illus- 
trations.   In  one  neat  vol.,  royal  12mo.,  extra  cloth,    pp.  350.    $1  25. 


BEALE  ON  THE  LAWS  OF  HEALTH  IN  RE- 
LATION TO  MIND  AND  BODY.  A  Series  of 
Letters  from  an  old  Practitioner  to  a  Patient.  In 
one  volume,  royal  12rno.,  extra  cloth-,  pp.  296. 
80  centB. 

BUSHNAN'S  PHYSIOLOGY  OF  ANIMAL  AND 
VEGETABLE  LIFE;  a  Popular  Treatise  on  the 
Functions  and  Phenomena  of  Organic  Life.  In 
one  handBome  royal  12mo.  volume,  extra  cloth, 
with  over  100  illustrations,    pp.234.    80  cents. 


BUCKLER  ON  THE  ETIOLOGY,  PATHOLOGY, 
AND  TREATMENT  OF  FIBRO-BRONCHI- 
TIS  AND   RHEUMATIC    PNEUMONIA.     In 

one  8vo.  volume,  extra  cloth,     pp.150.     $125. 

BLOOD  AND  URINE  (MANUALS  ON).  BY 
JOHN  WILLIAM  GRIFFITH,  G.  OWEN 
REESE,  AND  ALFRED  MARKWICK.  One 
thick  volume,  royal  12mo.,  extra  cloth,  with 
plates,    pp.  460.     $1  25. 

BRODIE'S  CLINICAL  LECTURES  ON  SUR- 
GERY.   1  vol.  8vo.,  cloth.    350  pp.    $1  25. 


AND    SCIENTIFIC    PUBLICATIONS. 


BARCLAY  (A.  W.)    M.  D., 

Assistant  Physician  to  St.  George's  Hospital,  &c. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS;   being  an  Analysis  of  the  Signs 

and  Symptoms  of  Disease.    In  one  neat  octavo  volume,  extra  cloth,  of  424  pages.    (Now  Ready.) 

$2  00. 


Of  works  exclusively  devoted  to  this  important 
branch,  our  profession  has  at  command,  compara- 
tively, but  few,  and,  therefore,  in  the  publication  of 
the  present  work,  Messrs.  Blanchard  &,  Lea  have 
conferred  a  great  favor  upon  us.  Dr.  Barclay,  from 
having  occupied,  for  a  long  period,  the  position  of 
Medical  Registrar  at  St.  George's  Hospital,  pos- 
sessed advantages  for  correct  observation  and  reli- 
able conclusions,  as  to  the  significance  of  symptoms, 
which  have  fallen  to  the  lot  of  but  few,  either  in 
his  own  or  any  other  country.  He  has  carefully 
systematized  the  results  of  his  observation  of  over 
twelve  thousand  patients,  and  by  his  diligence  and 
judicious  classification,  the  profession  has  been 
presented  with  the  most  convenient  and  reliable 
work  on  the  subject  of  Diagnosis  that  it  has  been 
our  good  fortune  ever  to  examine;  we  can,  there- 
fore, say  of  Dr.  Barclay's  work,  that,  from  his  sys- 
tematic manner  of  arrangement,  his  work  is  one  of 
the  best  works  "  for  reference"  in  the  daily  emer- 
gencies of  the  practitioner,  with  which  we  are  ac- 
quainted ;  but,  at  the  same  time,  we  would  recom 


has  not  exceeded  his  powers.  We  have  thus  given 
a  specimen  of  Barclay's  geneializing  spirit  in  one 
direction;  but  the  same  pervades  his  whole  work-, 
and  will,  we  are  sure,  induce  teachers  to  recommend 
it  strongly  to  their  pupils. (  It  is  impossible  for  us 
here  to  follow  the  book  into  its  particulars;  and,  in- 
deed, we  think  it  enough  to  indicate,  as  we  have  done, 
the  importance  of  the  teaching  which  it  offers  to  the 
rising  generation  of  medicine,  to  insure  for  it  a  hearty 
reception  at  the  hands  of  the  profession.  It  is  the 
work  of  a  physician  and  a  gentleman. — British  Med. 
Journal,  Dec.  5,  1857. 

We  hope  the  volume  will  have  an  extensive  cir- 
culation, not  among  students  of  medicine  only,  but 
practitioners  also.  They  will  never  regret  a  faith- 
ful study  of  its  pages. —  Cincinnati  Lancet,  Mar.  '58. 

This  Manual  of  Medical  Diagnosis  is  one  of  the 
most  scientific,  useful,  and  instructive  works  of  its 
kind  that  we  have  ever  read,  and  Dr.  Barclay  has 
done  good  service  to  medical  science  in  collecting, 
arranging,  and  analyzing  the  signs  and  symptoms 


mend  our  readers,  especially  the  younger  ones,  to  I  ?f  s°  many  diseases.     It  must  have  cost  him  great 
read  thoroughly  and  study  diligently  thewhole  work,    labor,  and  the  profession  should  snow  their  appre 


and  the  ';  emergencies"  will  not  occur  so  often. — 
Southern  Med.  and  Surg.  Joum.,  March,  1858. 


ciation  of  it  by  their  desire  to  procure  and  apply  its 
valuable  hints  and  suggestions  to  the  thousand  ob- 
scure cases  which  perplex  and  baffle  the  unaided 
efforts  of  any  one  man,  be  he  ever  so  wise,  and  his 
opportunities  ever  so  good.    Another  most  valuable 


To  give  this  information,  to  supply  this  admitted 
deficiency,  is  the  object  of  Dr.  Barclay's  Manual. 

The  task  of  composing  such  a  work  is  neither  an  \  feature  in  the  work  is  that  it  has  been  furnished 
easy  nor  a  light  one  ;  but  Dr.  Barclay  has  performed  !  with  a  copious  index,  which  increases   its  utility 
it  in  a  manner  which  meets  our  most  unqualified  j  very  much  as  a  volume  of  reference. — N.  J.  Med. 
approbation.    He  is  no  mere  theorist;  he  knows  his    and  Surg.  Reporter,  March,  1858. 
work  thoroughly,  and  in  attempting  to  perform  it,  I 


BARLOW   (GEORGE  H.),   M.D. 

Physician  to  Guy's  Hospital,  London,  &c. 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.     With  Additions  by  D- 

F.  Condie,  M.  D.,  author  of  "  A  Practical  Treatise  on  Diseases  of  Children,"  &c.    In  one  hand- 
some octavo  volume,  leather,  of  over  600  pages.     (A  new  work,  just  issued,  1856.)    $2  75. 


We  recommend  Dr.  Barlow's  Manual  in  the  warm- 
est manner  as  a  most  valuable  vade-mecum.  We 
have  had  frequent  occasion  to  consult  it,  and  have 
■found  it  clear,  concise,  practical,  and  sound.  It  is 
eminently  a  practical  work,  containing  all  that  is 
essential,  and  avoiding  useless  theoretical  discus- 
sion. The  work  supplies  what  has  been  for  some 
time  wanting,  a  manual  of  practice  based  upon  mo- 
dern discoveries  in  pathology  and  rational  views  of 
treatment  of  disease.  It  is  especially  intended  for 
the  use  of  students  and  junior  practitioners,  but  it 


will  be  found  hardly  less  useful  to  the  experienced 
physician.  The  American  editor  has  added  to  the 
work  three  chapters — on  Cholera  Infantum,  Yellow 
Fever,  and  Cerebro-spinal  Meningitis.  These  addi- 
tions, the  two  first  of  which  are  indispensable  to  a 
work  on  practice  destined  for  the  profession  in  this 
country,  are  executed  with  great  judgment  and  fi- 
delity, by  Dr.  Condie,  who  has  also  succeeded  hap- 
pily in  imitating  the  conciseness  and  clearness  of 
style  which  are  such  agreeable  characteristics  of 
the  original  book. — Boston  Med.  and  Surg.  Journal. 


BARTLETT  (ELISHA),  M.  D. 
THE   HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE   FEVERS 

OF  THE  UNITED  STATES.  A  new  and  revised  edition.  By  Alonzo  Clark,  M.  D.,  Prof, 
of  Pathology  and  Practical  Medicine  in  the  N.  Y.  College  of  Physicians  and  Surgeons,  &c.  In 
one  octavo  volume,  of  six  hundred  pages,  extra  cloth.  (Now  Ready.)  Price  $3  00. 


It  is  the  best  work  on  fevers  which  has  emanated 
from  the  American  press;  and  the  present  editor  has 
carefully  availed  himself  of  all  information  exist- 
ing upon  the  subject  in  the  Old  and  New  World,  so 
that  the  doctrines  advanced  are  brought  down  to  the 
latest  date  in  the  progress  of  this  department  of 
Medical  Science. — London  Med.  Times  and  Gazette, 
May  2,  1857. 

This  excellent  monograph  on  febrile  disease,  has 
stood  deservedly  high  since  its  first  publication.  It 
will  be  seen  that  it  has  now  reached  its  fourth  edi- 
tion under  the  supervision  of  Prof.  A.  Clark,  a  gen- 
tleman who,  from  the  nature  of  his  studies  and  pur- 
suits, is  well  calculated  to  appreciate  and  discuss 
the  many  intricate  and  difficult  questions  in  patho- 


logy. His  annotations  add  much  to  the  interest  of 
the  work,  and  have  brought  it  well  up  to  the  condi- 
tion of  the  science  as  it  exists  at  the  present  day 
in  regard  to  this  class  of  diseases. — Southern  Med. 
and  Surg.  Journal,  Mar.  1857. 

It  is  a  work  of  great  practical  value  and  interest, 
containing  much  that  is  new  relative  to  the  several 
diseases  of  which  it  treats,  and,  with  the  additions 
of  the  editor,  is  fully  up  to  the  times.  The  distinct- 
ive features  of  the  diflferentforms  of  fever  are  plainly 
and  forcibly  portrayed,  and  the  lines  of  demarcation 
carefully  and  accurately  drawn,  and  to  the  Ameri- 
can practitioner  is  a  more  valuable  and  safe  guide 
than  any  work  on  fever  extant. — Ohio  Med.  and 
Surg.  Journal,  May,  1857. 


CURLING    (T.    B.),    F.R.S., 
Surgeon  to  the  London  Hospital,  President  of  the  Hunterian  Society,  &c. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS,  SPERMA- 
TIC CCRD,  AND  SCROTUM.  Second  American,  from  the  second  and  enlarged  English  edi- 
tion.   In  one  handsome  octavo  volume,  extra  cloth,  with  numerous  illustrations,  pp.  420.  (Just 

|    Issued,  1S56.)    $2  00. 


BLANCHARD  &  LEA'S   MEDICAL 


CARPENTER  (WILLIAM    B.),   M.  D.,  F.  R.  S.,  &c, 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  applications  to 

Psychology,  Pathology,  Therapeutics,  Hygiene,  and  Forensic  Medicine.  A  new  American,  from 
the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations.  Edited,  with  addi- 
tions, by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  Pennsyl- 
vania Medical  College,  &c.  In  one  very  large  and  beautiful  octavo  volume,  of  about  nine  hundred 
large  pages,  handsomely  printed  and  strongly  bound  in  leather,  with  raised  bands.  {Just  Issued, 
1856.)    $4  25. 

In  the  preparation  of  this  new  edition,  the  author  has  spared  no  labor  to  render  it,  as  heretofore, 
a  complete  and  lucid  exposition  of  the  most  advanced  condition  of  its  important  subject.  The 
amount  of  the  additions  required  to  effect  this  object  thoroughly,  joined  to  the  former  large  size  of 
the  volume,  presenting  objections  arising  from  the  unwieldy  bulk  of  the  work,  he  has  omitted  all 
those  portions  not  bearing  directly  upon  Human  Physiology,  designing  to  incorporate  them  in 
his  forthcoming  Treatise  on  General  Physiology.  As  a  full  and  accurate  text-book  on  the  Phy- 
siology of  Man,  the  work  in  its  present  condition  therefore  presents  even  greater  claims  upon 
the  student  and  physician  than  those  which  have  heretofore  won  for  it  the  very  wide  and  distin- 
guished favor  which  it  has  so  long  enjoyed.  The  additions  of  Prof.  Smith  will  be  found  to  supply 
whatever  may  have  been  wanting  to  the  American  student,  while  the  introduction  of  many  new 
illustrations,  and  the  most  careful  mechanical  execution,  render  the  volume  one  of  the  most  at- 
tractive as  yet  issued. 


For  upwards  of  thirteen  years  Dr.  Carpenter's 
work  has  been  considered  by  the  profession  gene- 
rally, both  in  this  country  and  England,  as  the  most 
valuable  compendium  on  the  subject  of  physiology 
in  our  language.  This  distinction  it  owes  to  the  high 
attainments  and  unwearied  industry  of  its  accom- 
plished author.  The  present  edition  (which,  like  the 
last  American  one,  was  prepared  by  the  author  him- 
self), is  the  result  of  such  extensive  revision,  that  it 
may  almost  be  considered  a  new  work.  We  need 
hardly  say,  in  concluding  this  brief  notice,  that  while 
the  work  is  indispensable  to  every  student  of  medi- 
cine in  this  country,  it  will  amply  repay  the  practi- 
tioner for  its  perusal  by  the  interest  and  value  of  its 
contents. — Boston  Med.  and  Surg.  Journal. 

This  is  a  standard  work — the  text-book  used  by  all 
medical  students  who  read  the  English  language. 
It  has  passed  through  several  editions  in  order  to 
keep  pace  with  the  rapidly  growing  science  of  Phy- 
siology. Nothing  need  be  said  in  its  praise,  for  its 
merits  are  universally  known  ;  we  have  nothing  to 
say  of  its  defects,  for  they  only  appear  where  the 
science  of  which  it  treats  is  incomplete. — Western 
Lancet. 

The  most  complete  exposition  of  physiology  which 
any  language  can  at  present  give. — Brit,  and  For. 
Med.-Chirurg.  Review. 

The  greatest,  the  most  reliable,  and  the  best  book 
on  the  subject  which  we  know  of  in  the  English 
language. — Stethoscope. 


To  eulogize  this  great  work  would  be  superfluous 
We  should  observe,  however,  that  in  this  edition 
the  author  has  remodelled  a  large  portion  of  the 
former,  and  the  editor  has  added  much  matter  of  in- 
terest, especially  in  the  form  of  illustrations.  We 
may  confidently  recommend  it  as  the  most  complete 
work  on  Human  Physiology  in  our  language. — 
Southern  Med.  and  Surg.  Journal,  December,  1855. 

The  most  complete  work  on  the  science  in  our 
language. — Am.  Med.  Journal. 

The  most  complete  work  now  extant  in  our  lan- 
guage.— N.  O.  Med.  Register. 

The  best  text-book  in  the  language  on  this  ex- 
tensive subject. — London  Med.  Times. 

A  complete  cyclopaedia  of  this  branch  of  science. 
— N.  Y.  Med.  Times. 

The  profession  of  this  country,  and  perhaps  also 
of  Europe,  have  anxiously  and  for  some  time  awaited 
the  announcement  of  this  new  edition  of  Carpenter's 
Human  Physiology.  His  former  editions  have  for 
many  years  been  almost  the  only  text-book  on  Phy- 
siology in  all  our  medical  schools,  and  its  circula- 
tion among  the  profession  has  been  unsurpassed  by 
any  work  in  any  department  of  medical  science. 

It  is  quite  unnecessary  for  us  to  speak  of  this 
work  as  its  merits  would  justify.  The  mere  an- 
nouncement of  its  appearance  will  afford  the  highest 
pleasure  to  every  student  of  Physiology,  while  its 
perusal  will  be  of  infinite  service  in  advancing 
physiological  science. — Ohio  Med.  and  Surg.  Journ. 


BY  the  same  author.    (Lately  Issued.) 

PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.    New  American,  from 

the  Fourth  and  Revised  London  edition.     In  one  large  and  handsome  octavo  volume,  with  over 
three  hundred  beautiful  illustrations,    pp.  752.    Extra  cloth,  $4  80 ;  leather,  raised  bands,  $5  25. 

The  delay  which  has  existed  in  the  appearance  of  this  work  has  been  caused  by  the  very  thorough 
revision  ana  remodelling  which  it  has  undergone  at  the  hands  of  the  author,  and  the  large  number 
of  new  illustrations  which  have  been  prepared  for  it.  It  will,  therefore,  be  found  almost  a  new 
work,  and  fully  up  to  the  day  in  every  department  of  the  subject,  rendering  it  a  reliable  text-book 
for  all  students  engaged  in  this  branch  of  science.  Every  effort  has  been  made  to  render  its  typo- 
graphical finish  and  mechanical  execution  worthy  of  its  exalted  reputation,  and  creditable  to  the 
mechanical  arts  of  this  country. 

This  book  should  not  only  be  read  but  thoroughly 
studied  by  every  member  of  the  profession.  None 
are  too  wise  or  old,  to  be  benefited  thereby.  But 
especially  to  the  younger  class  would  we  cordially 
commend  it  as  best  fitted  of  any  work  in  the  English 
language  to  qualify  them  for  the  reception  and  com- 
prehension of  those  truths  which  are  daily  being  de- 
veloped in  physiology. — Medical  Counsellor. 

Without  pretending  to  it,  it  is  an  encyclopedia  of 
the  subject,  accurate  and  complete  in  all  respects— 
a  truthful  reflection  of  the  advanced  state  at  which 
the  science  has  now  arrived. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  truly  magnificent  work — in  itself  a  perfect  phy- 
siological study. — Ranking's  Abstract. 

This  work  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken ;  it  is  one 


no  man,  we  believe,  could  have  brought  to  so  suc- 
cessful an  issue  as  Dr.  Carpenter.  It  required  for 
its  production  a  physiologist  at  once  deeply  read  in 
the  labors  of  others,  capable  of  taking  a  general, 
critical,  and  unprejudiced  view  of  those  labors,  and 
of  combining  the  varied,  heterogeneous  materials  at 
his  disposal,  so  as  to  form  an  harmonious  whole. 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  its  unity,  of  the  admirable  manner  in  which 
material  has  been  brought,  from  the  most  various 
sources,  to  conduce  to  its  completeness,  of  the  lucid- 
ity of  the  reasoning  it  contains,  or  of  the  clearness 
of  language  in  which  the  whole  is  clothed.  Not  the 
profession  only,  but  the  scientific  world  at  large, 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  this 
great  work.  It  must,  indeed,  add  largely  even  to 
his  high  reputation. — Medical  Times. 


AND    SCIENTIFIC    PUBLICATIONS. 


,        CARPENTER  (WILLIAM  B.),   M.  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 
{Just  Issued,  1856.) 

THE  MICROSCOPE  AND  ITS  REVELATIONS.      With  an  Appendix  con- 

taining  the  Applications  of  the  Microscope  to  Clinical  Medicine,  &c.     By  F.  G.  Smith,  M,  D. 

Illustrated  by  lour  hundred  and  thirty-four  beautiful  engravings  on  wood.     In  one  large  and  verv 

handsome  octavo  volume,  of  724  pages,  extra  cloth,  $4  00  ;  leather,  $4  50. 

Dr.  Carpenter's  position  as  a  microscopist  and  physiologist,  and  his  great  experience  as  a  teacher 
eminently  qualify  him  to  produce  what  has  long  been  wanted — a  good  text-book  on  the  practical 
use  of  the  microscope.  In  the  present  volume  his  object  has  been,  as  stated  in  his  Preface,  "  to 
combine,  within  a  moderate  compass,  that  information  with  regard  to  the  use  of  his  '  tools,'  which 
is  most  essential  to  the  working  microscopist,  with  such  an  account  of  the  objects  best  fitted  for 
his  study,  as  might  qualify  him  to  comprehend  what  he  observes,  and  might  thus  prepare  him  to 
benefit  science,  whilst  expanding  and  refreshing  his  own  mind  "  That  he  has  succeeded  in  accom- 
plishing this,  no  one  acquainted  with  his  previous  labors  can  doubt. 

The  great  importance  of  the  microscope  as  a  means  of  diagnosis,  and  the  number  of  microsco- 
pists  who  are  also  physicians,  have  induced  the  American  publishers,  with  the  author's  approval,  to 
add  an  Appendix,  carefully  prepared  by  Pressor  Smith,  on  the  applications  of  the  instrument  to 
clinical  medicine,  together  with  an  accormt  of  American  Microscopes,  their  modifications  and 
accessories.  This  portion  of  the  work  is  illustrated  with  nearly  one  hundred  wood-cuts,  and,  it  is 
hoped,  will  adapt  the  volume  more  particularly  to  the  use  of  the  American  student. 

Every  care  has  been  taken  in  the  mechanical  execution  of  the  work,  which  is  confidently  pre- 
sented as  in  no  respect  inferior  to  the  choicest  productions  of  the  London  press. 

The  mode  in  which  the  author  has  executed  his  intentions  may  be  gathered  from  the  following 
condensed  synopsis  of  the 

CONTENTS. 

Introduction — History  of  the  Microscope.  Chap.  I.  Optical  Principles  of  the  Microscope. 
Chap.  II.  Construction  of  the  Microscope.  Chap.  III.  Accessory  Apparatus.  Chap.  IV. 
Management  of  the  Microscope  Chap.  V.  Preparation,  Mounting,  and  Collection  of  Objects. 
Chap.  VI.  Microscopic  Forms  of  Vegetable  Life — Protophytes.  Chap.  VII.  Higher  Cryptoga- 
mia.  Chap.  VIII.  Phanerogamic  Plants.  Chap.  IX.  Microscopic  Forms  of  Animal  Life — Pro- 
tozoa— Animalcules.  Chap.  X.  Foraminifera,  Polycystina,  and  Sponges.  Chap.  XI.  Zoophytes. 
Chap.  XII.  Echinodermata.  Chap.  XIII.  Polyzoa  and  Compound  Tunicata.  Chap.  XIV. 
Molluscous  Animals  Generally.  Chap.  XV.  Annulosa.  Chap.  XVI.  Crustacea.  Chap.  XVII. 
Insects  and  Arachnida.  Chap.  XVIII.  Vertebrated  Animals.  Chap.  XIX.  Applications  of  the 
Microscope  to  Geology.  Chap.  XX.  Inorgauic  or  Mineral  Kingdom — Polarization.  Appendix. 
Microscope  as  a  means  of  Diagnosis — Injections — Microscopes  of  American  Manufacture. 


Those  who  are  acquainted  with  Dr.  Carpenter's 
previous  writings  on\Animal  and  Vegetable  Physio- 
logy, will  fully  understand  how  vast  a  store  of  know- 
ledge he  is  able  to  bring  to  bear  upon  so  comprehen- 
sive a  subject  as  the  revelations  of  the  microscope  ; 
and  even  those  who  have  no  previous  acquaintance 
with  the  construction  or  uses  of  this  instrument, 
will  find  abundance  of  information  conveyed  in  clear 
and   simple  language. — Med.    Times  and   Gazette. 

Although  originally  not  intended  as  a  strictly 


medical  work,  the  additions  by  Prof.  Smith  give  it 
a  positive  claim  upon  the  profession,  for  which  we 
doubt  not  he  will  receive  their  sincere  thanks.  In- 
deed, we  know  not  where  the  student  of  medicine 
will  find  such  a  complete  and  satisfactory  collection 
of  microscopic  facts  bearing  upon  physiology  and 
practical  medicine  as  is  contained  in  Prof.  Smith's 
appendix;  and  this  of  itself,  it  seems  to  us,  is  fully 
worth  the  cost  of  the  volume. — Louisville  Medical 
Review.  Nov.  1856. 


BY  THE  SAME   AUTHOR. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 
LOGICAL ANATOMY.  Second  American,  from  a  new  and  revised  London  edition.  With 
one  hundred  and  ninety  illustrations.  In  one  very  handsome  octavo  volume,  leather,  pp.  566. 
$3  00. 

In  publishing  the  first  edition  of  this  work,  its  title  was  altered  from  that  of  the  London  volume, 
by  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  and  with  the  author's  sanction 
the  title  of  "Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise. 


To  say  that  it  is  the  best  manual  of  Physiology 
now  before  the  public ,  would  not  do  sufficient  justice 
to  the  author. — Buffalo  Medical  Journal. 

In  his  former  works  it  would  seem  that  he  had 
exhausted  the  subjectof  Physiology.  In  the  present, 
he  gives  the  essence,  as  it  were,  of  the  whole. — N.  Y. 
Journal  of  Medicine. 


Those  who  have  occasion  for  an  elementary  trea- 
tise on  Physiology,  cannot  do  better  than  to  possess 
themselves  of  the  manual  of  Dr.  Carpenter. — Medical 
Examiner. 

The  best  and  most  complete  expose"  of  modern 
Physiology,  in  one  volume,  extant  in  the  English 
language. — St.  Louis  Medical  Journal. 


BY  the  same  author.     (Preparing.) 

PRINCIPLES  OF   GENERAL   PHYSIOLOGY,    INCLUDING   ORGANIC 

CHEMISTRY  AND  HISTOLOGY.    With  a  General  Sketch  of  the  Vegetable  and  Animal 
Kingdom.    In  one  large  and  very  handsome  octavo  volume,  with  several  hundred  illustrations. 
The  subject  of  general  physiology  having  been  omitted  in  the  last  editions  of  the  author's  "  Com- 
parative Physiology"  and  '"'Human  Physiology,"  he  has  undertaken  to  prepare  a  volume  which 
shall  present  it  more  thoroughly  and  fully  than  has  yet  been  attempted,  and  which  may  be  regarded 
as  an  introduction  to  his  other  works. 


BY  THE   SAME   AUTHOR. 


A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DISEASE.    New  edition",  with  a  Preface  by  D.  F.  Condie,  M.  D.,  and  explanations  of 
scientifio  words.    In  one  neat  12mo.  volume,  extra  cloth,    pp.  178.    50  cents. 


8 


BLANCHARD  &  LEA'S  MEDICAL 


CONDIE  (D.  FJ,  M.  D.,  &c. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN.    Fourth 

edition,  revised  and  augmented.    In  one  large  volume,  8vo.,  leather,  of  nearly  750  pages.  $3  00. 
From  the  Author's  Preface. 

The  demand  for  another  edition  has  afforded  the  author  an  opportunity  of  again  subjecting  the 
entire  treatise  to  a  careful  revision,  and  of  incorporating  in  it  every  important  observation  recorded 
since  the  appearance  of  the  last  edition,  in  reference  to  the  pathology  and  therapeutics  of  the  several 
diseases  of  which  it  treats. 

In  the  preparation  of  the  present  edition,  as  in  those  which  have  preceded,  while  the  author  has 
appropriated  to  his  use  every  important  fact  that  he  has  found  recorded  in  the  works  of  others, 
having  a  direct  bearing  upon  either  of  the  subjects  of  which  he  treats,  and  the  numerous  valuable 
observations — pathological  as  well  as  practical — dispersed  throughout  the  pages  of  the  medical 
journals  of  Europe  and  America,  he  has,  nevertheless,  relied  chiefly  upon  his  own  observations  and 
experience,  acquired  during  a  long  and  somewhat  extensive  practice,  and  under  circumstances  pe- 
culiarly well  adapted  for  the  clinical  study  of  the  diseases  of  early  life. 

Every  species  of  hypothetical  reasoning  has,  as  much  as  possible,  been  avoided.  The  author  has 
endeavored  throughout  the  work  to  confine  himself  to  a  simple  statement  of  well-ascertained  patho- 
logical facts,  and  plain  therapeutical  directions— his ^lief  desire  being  to  render  it  what  its  title 
imports  it  to  be,  a  practical  treatise  on  the  diseases  of  children. 


Dr.  Condie's  scholarship,  acumen?  industry,  and 
practical  sense  are  manifested  in  this,  as  in  all  his 
numerous  contributions  to  science. — Dr.  Holmes's 
Report  to  the  American  Medical  Association. 

Taken  as  a  whole,  in  our  judgment,  Dr.  Condie's 
Treatise  is  the  one  from  the  perusal  of  which  the 
practitioner  in  this  country  will  rise  with  the  great- 
est satisfaction.— Western  Journal  of  Medicine  and 
Surgery. 

One  of  the  best  works  upon  the  Diseases  of  Chil- 
dren in  the  English  language. — Western  Lancet. 

Perhaps  the  most  full  and  complete  work  now  be- 
fore the  profession  of  the  United  States ;  indeed,  we 
may  say  in  the  English  language.  It  is  vastly  supe- 
rior to  most  of  its  predecessors. — Transylvania  Med. 
Journal, 


We  feel  assured  from  actual  experience  that  no 
physician's  library  can  be  complete  without  a  copy 
of  this  work.— N.  Y.  Journal  of  Medicine. 

A  veritable  pediatric  encyclopsedia,  and  an  honor 
to  American  medical  literature. — Ohio  Medical  and 
Surgical  Journal. 

We  feel  persuaded  that  the  American  medical  pro- 
fession will  soon  regard  it  not  only  as  a  very  good, 
but  as  the  very  best  "Practical  Treatise  *n  the 
Diseases  of  Children." — American  Medical  Journal . 

We  pronounced  the  first  edition  to  he.  the  best 
work  on  the  diseases  of  children  in  the  English 
language,  and,  notwithstanding  all  that  has  been 
published,  we  still  regard  it  in  that  light. — Medical 
Examiner. 


CHRISTISON  (ROBERT),  M.  D./ V.  P.  R.  S.  E.,  &c. 
A  DISPENSATORY;  or,  Commentary  on  the  Pharmacopoeias  of  Great  Britain 

and  the  United  States ;  comprising  the  Natural  History,  Description,  Chemistry,  Pharmacy,  Ac- 
tions, Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica.  Second  edition,  revised  and  im- 
proved, with  a  Supplement  containing  the  most  important  New  Remedies.  With  copious  Addi- 
tions, and  two  hundred  and  thirteen  large  wood-engravings.  By  R.  Eglesfeld  Griffith,  M.  D. 
In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  of  over  1000  pages.  $3  50. 

It  is  not  needful  that  wfl  should  compare  it  with  I  this  branch  of  knowledge  which  the  student  has  a 
the  other  pharmacopoeias  extant,  which  enjoy  and  I  right  to  expect  in  such  a  work,  we  confess  the  omis- 
merit  the  confidence  of  the  profession  :  it  is  enough  sion  has  escaped  our  scrutiny.  We  cordially recom- 
to  say  that  it  appears  to  us  as  perfect  as  a  Dispensa-  mend  this  work  to  such  of  our  readers  as  are  in  need 
tory,  in  the  present  state  of  pharmaceutical  science,  of  a  Dispensatory.  They  cannot  makcchoice  of  a 
could  be  made.    If  it  omits  any  details  pertaining  to     better. — Western  Journ.  of  Medicine  and  Surgery. 


COOPER  (BRANSBY  B.),  F.  R.  S. 
LECTURES  ON  THE  PRINCIPLES  AND   PRACTICE   OF   SURGERY. 

In  one  very  large  octavo  volume,  extra  cloth,  of  750  pages.    $3  00. 


COOPER  ON  DISLOCATIONS  AND  FRAC- 
TURES OF  THE  JOINTS.— Edited  by  Bransby 
B.  Cooper,  F.  R.  S.,  &c.  With  additional  Ob- 
servations by  Prof.  J.  C.  Warren.  A  new  Ame- 
rican edition.  In  one  handsome  octavo  volume, 
extra  cloth,  of  about  500  pages,  with  numerous 
illustrations  on  wood.    $3  25. 

COOPER  ON  THE  ANATOMY  AND  DISEASES 
OF  THE  BREAST,  with  twenty-five  Miscellane- 
ous and  Surgical  Papers.  One  large  volume,  im- 
perial 8vo.,  extra  cloth,  with  252  figures,  on  36 
plates.    $2  50. 

COOPER  ON  THE  STRUCTURE  AND  DIS- 
EASES OF  THE  TESTIS,  AND  ON  THE 
THYMUS  GLAND.  One  vol.  imperial  8vo.,  ex- 
tra cloth,  with  177  figures  on  29  plates.    $2  00. 


COPLAND  ON  THE  CAUSES,  NATURE,  AND 
TREATMENT  OF  PALSY  AND  APOPLEXY  . 

In  one  volume,  royal  12mo.,  extra  cloth,  pp.  326. 
80  cents. 

CLYMER  ON  FEVERS;  THEIR  DIAGNOSIS, 
PATHOLOGY,  AND  TREATMENT  In  one 
octavo  volume,  leather,  of  600  pages.    $1  50. 

COLOMBAT  DE  L'ISERE  ON  THE  DISEASES 
OF  FEMALES,  and  on  the  special  Hygiene  of 
their  Sex.  Translated,  with  many  Notes  and  Ad- 
ditions, by  C.  D.  Meigs,  M.  D.  Second  edition, 
revised  and  improved.  In  one  large  volume,  oc- 
tavo, leather,  with  numerous  wood-cuts.  pp.  720. 
$3  50. 


CARSON  (JOSEPH),  M.  D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania. 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA  MEDICA 

AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.    Second  and  revised  edi- 
tion.   In  one  very  neat  octavo  volume,  extra  cloth,  of  208  pages.    $1  50. 


AND    SCIENTIFIC    PUBLICATIONS. 


CHURCHiki.  (FU^ETWOOD),  M.  D.,  M.  R.  I.  A. 
ON  THE  THEORY  AND  PRAC'm^   OF  Mll>  ir xi^.ry.     Edited    with 

Notes  and  Additions,  by  D.  Francis  Condie,  M.  d.,  author  of  a  "Practice  Treatjse,on  tne 
Diseases  of  Children,"  dec.  With  139  illustrations.  In  one  very  handsome  oct'avC  -o„me 
leather,    pp.510.     $3  00. 


To  bestow  praise  on  a  book  that  has  received  such 
marked  approbation  would  be  superfluous.  We  need 
only  say,  therefore,  that  if  the  first  edition  was 
thought  worthy  of  a  favorable  reception  by  the 
medical  public,  we  can  confidently  affirm  that  this 
will  be  found  much  more  so.  The  lecturer,  the 
practitioner,  and  the  student,  may  all  have  recourse 
to  its  pages,  and  derive  from  their  perusal  much  in- 
terest and  instruction  in  everything  relating  to  theo- 
retical and  practical  midwifery.— Dublin  Quarterly 
Journal  of  Medical  Science. 

A  work  of  very  great  merit,  and  such  as  we  can 
confidently  recommend  to  the  study  of  every  obste- 
tric practitioner. — London  Medical  Gazette. 

This  is  certainly  the  most  perfect  system  extant. 
It  is  the  best  adapted  for  the  purposes  of  a  text- 
book, and  that  which  he  whose  necessities  confine 
him  to  one  book,  should  select  in  preference  to  all 
others. — Southern  Medical  and  Surgical  Journal. 

The  most  popular  work  on  midwifery  ever  issued 
from  the  American  press. — Charleston  Med.  Journal. 

Were  we  reduced  to  the  necessity  of  having  but 
one  work  on  midwifery,  and  permitted  to  choose, 
we  would  unhesitatingly  take  Churchill. — Western 
Med.  and  Surg.  Journal. 

It  is  impossible  to  conceive  a  more  useful  and 
elegant  manual  than  Dr.  Churchill's  Practice  of 
Midwifery. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
the  subject  which  exists. — N.  Y.  Annalist. 


No  work  holds  a  higher  position,  or  is  more  de- 
serving of  being  placed  in  the  hands  of  the  tyro, 
the  advanced  student,  or  the  practitioner. — Medical 
Examiner. 

Previous  editions,  under  the  editorial  supervision 
of  Prof  R.  M.  Huston,  have  been  received  with 
marked  favor,  and  they  deserved  it;  but  this,  re- 
printed from  a  very  late  Dublin  edition,  carefully 
revised  and  brought  up  by  the  author  to  the  present 
time,  does  present  an  unusually  accurate  and  able 
exposition  of  every  important  particular  embraced 
in  the  department  of  midwifery.  *  *  The  clearness, 
directness,  and  precision  of  its  teachings,  together 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  in. 
the  foremost  rank  of  works  in  this  department  of  re- 
medial science. — N.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  the 
very  best  text-book  and  epitome  of  obstetric  science 
which  we  at  present  possess  in  the  English  lan- 
guage.— Monthly  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  great  amount  of  statistical  research 
which  it  contains,  have  served  to  place  it  in  the  first 
rank  of  works  in  this  departmentof  medical  science. 
—  JV".  Y.  Journal  of  Medicine. 

Few  treatises  will  be  found  better  adapted  as  a 
text-book  for  the  student,  or  as  a  manual  for  the 
frequent  consultation  of  the  young  practitioner. — 
American  Medical  Journal. 


BY  THE  SAME  AUTHOR.     (J list  Issued.) 

ON  THE  DISEASES  OF  INFANTS  AND  CHILDREN.     Second  American 

Edition,  revised  and  enlarged  by  the  author.    Edited,  with  Notes,  by  W.  V.  Keating,  M.  D.    In 

one  large  and  handsome  volume,  extra  cloth,  of  over  700  pages.    $3  00,  or  in  leather,  $3  25. 

In  preparing  this  work  a  second  time  for  the  American  profession,  the  author  has  spared  no 
labor  in  giving  it  a  very  thorough  revision,  introducing  several  new  chapters,  and  rewriting  others, 
while  every  portion  of  the  volume  has  been  subjected  to  a  severe  scrutiny.  The  efforts  of  the 
American  editor  have  been  directed  to  supplying  such  information  relative  to  matters  peculiar 
to  this  country  as  might  have  escaped  the  attention  of  the  author,  and  the  whole  may,  there- 
fore, be  safely  pronounced  one  of  the  most  complete  works  on  the  subject  accessible  to  the  Ame- 
rican Profession.  By  an  alteration  in  the  size  of  the  page,  these  very  extensive  additions  have 
been  accqmmodated  without  unduly  increasing  the  size  of  the  work. 

A  few  notices  of  the  former  edition  are  subjoined : — 


We  regard  this  volume  as  possessing  more  claims 
to  completeness  than  any  other  of  the  kind  with 
which  we  are  acquainted.  Most  cordially  and  ear- 
nestly ,  therefore,  do  we  commend  it  to  our  profession- 
al brethren,  and  we  feel  assured  that  the  stamp  of 
their  approbation  will  in  due  time  be  impressed  upon 
it.  After  an  attentive  perusal  of  its  contents,  we 
hesitate  not  to  say,  that  it  is  one  of  the  most  com- 
prehensive ever  written  upon  the  diseases  of  chil- 
dren, and  that,  for  copiousness  of  reference,  extent  of 
research,  and  perspicuity  of  detail,  it  is  scarcely  to 
be  equalled,  and  not  to  be  excelled,  in  any  lan- 
guage.— Dublin  Quarterly  Journal. 

After  this  meagre,  and  we  know,  very  imperfect 
notice  of  Dr.  Churchill's  work,  we  shall  conclude 
by  saying,  that  it  is  one  that  cannot  fail  from  its  co- 
piousness, extensive  research,  and  general  accuracy, 
to  exalt  still  higher  the  reputation  of  the  author  in 
this  country.  The  American  reader  willbenarticu- 
larly  pleased  to  find  that  Dr.  Churchill  has  done  full 
justice  throughout  his  work  to  the  various  A  merican 
authors  on  this  subject.  The  names  of  Dewees, 
Eberle,  Condie,  and  Stewart,  occur  on  nearly  every 
page,  and  these  authors  are  constantly  referred  toby 
the  author  in  terms  of  the  highest  praise,  and  with 
the  most  liberal  courtesy. — The  Medical  Examiner. 


The  present  volume  will  sustain  the  reputation 
acquired  by  the  author  from  his  previous  works. 
The  reader  will  find  in  it  full  and  judicious  direc- 
tions for  the  management  of  infants  at  birth,  and  a 
compendious,  but  clear  account  of  the  diseases  to 
which  children  are  liable,  and  the  most  successful 
mode  of  treating  them.  We  must  not  close  this  no- 
tice without  calling  attention  to  the  author's  style, 
which  is  perspicuous  and  polished  to  a  degree,  we 
regret  to  say,  not  generally  characteristic  of  medical 
works.  We  recommend  the  work  of  Dr.  Churchill 
most  cordially,  both  to  students  and  practitioners, 
as  a  valuable  and  reliable  guide  in  the  treatment  of 
the  diseases  of  children. — Am.  Journ.  of  the  Med. 
Sciences. 

We  know  of  no  work  on  this  department  of  Prac- 
tical Medicine  which  presents  so  candid  and  unpre- 
judiced a  statement  or  posting  up  of  our  actual 
knowledge  as  this. — JV".  Y.  Journal  of  Medicine. 

Its  claims  to  merit  both  as  a  scientific  and  practi- 
cal work,  are  of  the  highest  order.  Whilst  we 
would  not  elevate  it  above  every  other  treatise  on 
the  same  subject,  we  certainly  believe  that  very  few 
are  equal  to  it,  and  none  superior. — Southern  Med. 
and  Surgical  Journal. 


BY   THE   SAME   AUTHOR. 


ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES  PE- 
CULIAR TO  WOMEN.  Selected  from  the  writings  of  British  Authors  previous  to  the  close  of 
the  Eighteenth  Century.    In  one  neat  octavo  volume,  extra  cloth,  of  about  450  pages.    $2  50. 


10 


BLANCHARD    &    LEA'S    MEDICAL 


CHURCHILL  (FLEETWOOD),  *♦-  D..  *f.  R.  I.  A.,  &c. 
ON  THE  DISE  A  e^^  ^  WOMEN/  including  those  of  Pregnancy  and  Child- 
bed A  i*"-*  Alnerican  edition,  revised  by  the  Author.  With  Notes  and  Additions,  by  D.  Fran- 
_.^  Condie,  M.  D.,  author  ot  "  A  Practical  Treatise  on  the  Diseases  of  Children."  With  nume- 
rous illustrations.  In  one  large  and  handsome  octavo  volume,  leather,  of  768  pages.  (Now  Ready, 
May,  1857.)    $3  00. 

This  edition  of  Dr.  Churchill's  very  popular  treatise  may  almost  be  termed  a  new  work,  so 
thoroughly  has  he  revised  it  in  every  portion.  It  will  be  found  greatly  enlarged,  and  thoroughly 
brought  up  to  the  most  recent  condition  of  the  subject,  while  the  very  handsome  series  of  illustra- 
tions introduced,  representing  such  pathological  conditions  as  can  be  accurately  portrayed,  present 
a  novel  feature,  and  afford  valuable  assistance  to  the  young  practitioner.  Such  additions  as  ap- 
peared desirable  for  the  American  student  have  been  made  by  the  editor,  Dr.  Condie,  while  a 
marked  improvement  in  the  mechanical  execution  keeps  pace  with  the  advance  in  all  other  respects 
which  the  volume  has  undergone,  while  the  price  has  been  kept  at  the  former  very  moderate  rate. 
A  few  notices  of  the  former  edition  are  subjoined : — 


It  comprises,  unquestionably,  one  of  the  most  ex- 
act and  comprehensive  expositions  of  the  present 
state  of  medical  knowledge  in  respect  to  the  diseases 
of  women  that  has  yet  been  published. — Am.  Journ. 
Med.  Sciences,  July,  1857. 

We  hail  with  much  pleasure  the  volume  before 
us,  thoroughly  revised,  corrected,  and  brought  up 
to  the  latest  date,  by  Dr.  Churchill  himself,  and 
rendered  still  more  valuable  by  notes,  from  the  ex- 
perienced and  able  pen  of  Dr.  D.  F.  Condie,  of  Phil- 
adelphia.— Southern  Med.  and  Surg.  Journal,  Oct. 
1857. 

This  work  is  the  most  reliable  -which  Ave  possess 
on  this  subject;  and  is  deservedly  popular  with  the 
profession. — Charleston  Med.  Journal,  July,  1857. 

Dr.  Churchill's  treatise  on  the  Diseases  of  Women 
is,  perhaps,  the  most  popular  of  his  works  with  the 
profession  in  this  country.  It  has  been  very  gene- 
rally received  both  as  a  text-book  and  manual  of 
practice.  The  present  edition  has  undergone  the 
most  elaborate  revision,  and  additions  of  an  import- 
ant character  have  been  made,  to  render  it  a  com- 
plete exponent  of  the  present  state  of  our  knowledge 
of  these  diseases. — N.  Y.  Journ.  of  Med.,  Sept.  1857. 

We  now  regretfully  take  leave  of  Dr.  Churchill's 
book.  Had  our  typographical  limits  permitted,  we 
should  gladly  have  borrowed  more  from  its  richly 
stored  pages.  In  conclusion,  we  heartily  recom- 
mend it  to  the  profession,  and  would  at  the  same 
time  express  our  firm  conviction  that  it  will  not  only 
add  to  the  reputation  of  its  author,  but  will  prove  a 
work  of  great  and  extensive  utility  to  obstetric 
practitioners. — Dublin  Medical  Press. 

We  know  of  no  author  who  deserves  that  appro- 
bation, on  "the  diseases  of  females,"  to  the  same 


extent  that  Dr.  Churchill  does.  His,  indeed,  is  the 
only  thorough  treatise  we  know  of  on  the  subject ; 
and.it  may  be  commended  to  practitioners  and  stu- 
dents as  a  masterpiece  in  its  particular  department. 
The  former  editions  of  this  work  have  been  com- 
mended strongly  in  this  journal,  and  they  have  won 
their  way  to  an  extended,  and  a  well-deserved  popu- 
larity. This  fifth  edition,  before  us,  is  well  calcu- 
lated to  maintain  Dr.  Churchill's  high  reputation. 
It  was  revised  and  enlarged  by  the  author,  for  his 
American  publishers,  and  it  seems  to  us  that  there  is 
scarcely  any  species  of  desirable  information  on  its 
subjects  that  may  not  be  found  in  this  work. — Tkt 
Western  Journal  of  Medicine  and  Surgery. 

We  are  gratified  to  announce  a  new  and  revised 
edition  of  Dr.  Churchill's  valuable  work  on  the  dis- 
eases of  females  We  have  ever  regarded  it  as  one 
of  the  very  best  works  on  the  subjects  embraced 
within  its  scope,  in  the  English  language;  and  the 
present  edition,  enlarged  and  revised  by  the  author, 
renders  it  still  more  entitled  to  the  confidence  of  the 
profession.  The  valuable  notes  of  Prof.  Huston 
have  been  retained,  and  contribute,  in  no  small  de- 
gree, to  enhance  the  value  of  the  work.  It  is  a 
source  of  congratulation  that  the  publishers  have 
permitted  the  author  to  be,  in  this  instance,  his 
own  editor,  thus  securing  all  the  revision  which 
an  author  alone  is  capable  of  making. — The  Western 
Lancet. 

As  a  comprehensive  manual  for  students,  or  a 
work  of  reference  for  practitioners,  we  only  speak 
with  common  justice  when  we  say  that  it  surpasses 
any  other  that  has  ever  issued  on  the  same  sub- 
ject from  the  British  press. — The  Dublin  Quarterly 
Journal. 


DICKSON   (S.    H.),    M.  D., 

Professor  of  Institutes  and  Practice  of  Medicine  in  the  Medical  College  of  South  Carolina. 

ELEMENTS  OF  MEDICINE;   a  Compendious  View  of  Pathology  and  Thera- 
peutics, or  the  History  and  Treatment  of  Diseases.    In  one  large  and  handsome  octavo  volume, 
of  750  pages,  leather      {Lately  Issued.)    $3  75. 
As  an  American  text- book  on  the  Practice  of  Medicine  for  the  student,  and  as  a  condensed  work 

of  reference  for  the  practitioner,  this  volume  will  have  strong  claims  on  the  attention  of  the  profession. 

Few  physicians  have  had  wider  opportunities  than  the  author  for  observation  and  experience,  and 

few  perhaps  have  used  them  better.    As  the  result  of  a  life  of  study  and  practice,  therefore,  the 

present  volume  will  doubtless  be  received  with  the  welcome  it  deserves. 
This  book  is  eminently  what  it  professes  to  be;  a 

distinguished   merit  in  these  days.      Designed  for 

"  Teachers  and  Students  of  Medicine,"  and  admira- 
bly suited  to  their  wants,  we  think  it  will  be  received, 

on  its  own  merits,  with  a  hearty  welcome. — Boston 

Med.  and  Surg.  Journal. 


Indited  by  one  of  the  most  accomplished  writers 
of  our  country,  as  well  as  by  one  who  has  long  held 
a  high  position  among  teachers  and  practitioners  of 
medicine,  this  work  is  entitled  to  patronage  and 
careful  study.  The  learned  author  has  endeavored 
to  condense  in  this  volume  most  of  the  practical 
matter  contained  in  his  former  productions,  so  as  to 
adapt  it  to  the  use  of  those  who  have  not  time  to 
devote  to  more  extensive  works. — Southern  Med.  and 
Surg.  Journal. 

Prof.  Dickson's  work  supplies,  to  a  great  extent, 
a  desideratum  long  felt  in  American  medicine. — N. 
O.  Med.  and  Surg.  Journal. 

Estimating  this  work  according  to  the  purpose  for 
which  it  is  designed,  we  must  think  highly  of  its 


merits,  and  we  have  no  hesitation  in  predicting  for 
it  a  favorable  reception  by  both  students  and  teachers. 

Not  professing  to  be  a  complete  and  comprehensive 
treatise,  it  will  not  be  found  full  in  detail,  nor  filled 
with  discussions  of  theories  and  opinions,  but  em- 
bracing all  that  is  essential  in  theory  and  practice, 
it  is  admirably  adapted  to  the  wants  of  the  American 
student.  Avoiding  all  that  is  uncertain,  it  presents 
more  clearly  to  the  mind  of  the  reader  that  which  is 
established  and  verified  by  experience.  The  varied 
and  extensive  reading  of  the  author  is  conspicuously 
apparent,  and  all  the  recent  improvements  and  dis- 
coveries in  therapeutics  and  pathology  are  chroni- 
cled in  its  pages. —  Charleston  Med.  Journal. 

In  the  first  part  of  the  work  the  subject  of  gene- 
ral pathology  is  presented  in  outline,  giving  a  beau- 
tiful picture  of  its  distinguishing  features,  and 
throughout  the  succeeding  chapters  we  find  that  he 
has  kept  scrupulously  within  the  bounds  of  sound 
reasoning  and  legitimate  deduction.  Upon  the 
whole,  we  do  not  hesitate  to  pronounce  it  a  superior 
work  in  its  class,  and  that  Dr.  Dickson  merits  a 
place  in  the  first  rank  of  American  writers. — Western 
Lancet. 


AND    SCIENTIFIC    PUBLICATIONS. 


11 


DRUITT   (ROBERT),   M.R.  C.S.,   &.C. 
THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY.     Edited 

by  F.  W.  Sargent,  M.  D.,  author  of  "  Minor  Surgery,"  &c.  Illustrated  with  one  hundred  and 
ninety-three  wood-engravings.  In  one  very  handsomely  printed  octavo  volume,  leather,  of  576 
large  pages.     $3  00. 


Dr.  Druitt's  researches  into  the  literature  of  his 
subject  have  been  not  only  extensive,  but  well  di- 
rected ;  the  most  discordant  authors  are  fairly  and 
impartially  quoted,  and,  while  due  credit  is  given 
to  each,  their  respective  merits  are  weighed  with 
an  unprejudiced  hand.  The  grain  of  wheat  is  pre- 
served, and  the  chaff  is  unmercifully  stripped  off. 
The  arrangement  is  simple  and  philosophical,  and 
the  style,  though  clear  and  interesting,  is  so  precise, 
that  the  book  contains  more  information  condensed 
into  a  few  words  than  any  other  surgical  work  with 
which  we  are  acquainted. — London  Medical  Times 
and  Gazette. 

No  work,  in  our  opinion,  equals  it  in  presenting 
so  much  valuable  surgical  matter  in  so  small  a 
compass. — St.  Louis  Med.  and  Surgical  Journal. 

Druitt's  Surgery  is  too  well  known  to  the  Ameri- 
can medical  profession  to  require  its  announcement 
anywhere.  Probably  no  work  of  the  kind  has  ever 
been  more  cordially  received  and  extensively  circu- 
lated than  this.  The  fact  that  it  comprehends  in  a 
comparatively  small  compass,  all  the  essential  ele- 
ments of  theoretical  and  practical  Surgery — that  it 
is  found  to  contain  reliable  and  authentic  informa- 
tion on  the  nature  and  treatment  of  nearly  all  surgi- 
cal affections — is  a  sufficient  reason  for  the  liberal 
patronage  it  has  obtained.  The  editor,  Dr.  F.  W. 
Sargent,  has  contributed  much  to  enhance  the  value 
of  the  work,  by  such  American  improvements  as  are 
calculated  more  perfectly  to  adapt  it  to  our  own 
views  and  practice  in  this  country.  It  abounds 
everywhere  with  spirited  and  life-like  illustrations, 
which  to  the  young  surgeon,  especially,  are  of  no 
minor  consideration.  Every  medical  man  frequently 
nteds  just  such  a  work  as  this,  for  immediate  refer- 
ence in  moments  of  sudden  emergency,  when  he  has 
not  time  to  consult  more  elaborate  treatises. — The 
Ohio  Medical  and  Surgical  Journal. 

The  author  has  evidently  ransacked  every  stand- 
ard treatise  of  ancient  and  modern  times,  and  all  that 


is  really  practically  useful  at  the  bedside  will  be 
found  in  a  form  at  once  clear,  distinct,  and  interest- 
ing.— Edinburgh  Monthly  Medical  Journal. 

Druitt's  work,  condensed,  systematic,  lucid,  and 
practical  as  it  is,  beyond  most  works  on  Surgery 
accessible  to  the  American  student,  has  had  much 
currency  in  this  country,  and  under  its  present  au- 
spices promises  to  rise  to  yet  higher  favor. — The 
Western  Journal  of  Medicine  and  Surgery. 

The  most  accurate  and  ample  resumfe  of  the  pre- 
sent state  of  Surgery  that  we  are  acquainted  with. — 
Dublin  Medical  Journal. 

A  better  book  on  the  principles  and  practice  of 
Surgery  as  now  understood  in  England  and  America, 
has  not  been  given  to  the  profession.— Boston  Medi- 
cal and  Surgical  Journal. 

An  unsurpassable  compendium,  not  only  of  Sur- 
gical, but  of  Medical  Practice. — London  Medical 
Gazette. 

This  work  merits  our  warmest  commendations, 
and  we  strongly  recommend  it  to  young  surgeons  as 
an  admirable  digest  of  the  principles  and  practice  of 
modern  Surgery. — Medical  Gazette. 

It  may  be  said  with  truth  that  the  work  of  Mr. 
Druitt  affords  a  complete,  though  brief  and  con- 
densed view,  of  the  entire  field  of  modern  surgery. 
We  know  of  no  work  on  the  same  subject  having  the 
appearance  of  a  manual,  which  includes  so  many 
topics  of  interest  to  the  surgeon  ;  and  the  terse  man- 
ner in  which  each  has  been  treated  evinces  a  most 
enviable  quality  of  mind  on  the  part  of  the  author, 
who  seems  to  have  an  innate  power  of  searching 
out  and  grasping  the  leading  facts  and  features  of 
the  most  elaborate  productions  of  the  pen.  It  is  a 
useful  handbook  for  the  practitioner,  and  we  should 
deem  a  teacher  of  surgery  unpardonable  who  did  not 
recommend  it  to  his  pupils.  In  our  own  opinion,  it 
is  admirably  adapted  to  the  wants  of  the  student. — 
Provincial  Medical  and  Surgical  Journal. 


DUNGLISON,   FORBES,   TWEEDIE,   AND   CONOLLY. 
THE  CYCLOPAEDIA  OF  PRACTICAL  MEDICINE:  comprising  Treatises  on 

the  Nature  and  Treatment  of  Diseases,  Materia  Medica,  and  Therapeutics,  Diseases  of  Women 
and  Children,  Medical  Jurisprudence,  &c.  &c.  In  four  large  super-royal  octavo  volumes,  of 
3254  double-columned  pages,  strongly  and  handsomely  bound,  with  raised  bands.  $12  00. 
*■%*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed  by 
sixty-eight  distinguished  physicians,  rendering  it  a  complete  library  of  reference  for  the  country 
practitioner. 

The  most  complete  work  on  Practical  Medicine  !  titioner.    This  estimate  of  it  has  not  been  formed 
extant;    or,  at  least,  in    our    language.—  Buffalo  j  from  a  hasty  examination,  but  after  an  intimate  ac- 

'  quaintance  derived  from  frequent  consultation  of  it 
during  the  past  nine  or  ten  years.  The  editors  are 
practitioners  of  established  reputation,  and  the  list 
of  contributors  embraces  many  of  the  most  eminent 
professors  and  teachers  of  London,  Edinburgh,  Dub- 
lin, and  Glasgow.  It  is,  indeed,  the  great  merit  of 
this  work  that  the  principal  articles  have  been  fur- 
nished by  practitioners  who  have  not  only  devoted 
especial  attention  to  the  diseases  about  which  they 
have  written,  but  have  also  enjoyed  opportunities 
for  an  extensive  practical  acquaintance  with  them, 
and  whose  reputation  carries  the  assurance  of  their 
competency  justly  to  appreciate  the  opinions  of 
others,  while  it  stamps  their  own  doctrines  with 
high  and  just  authority. — American  Medical  Journ. 


Medical  and  Surgical  Journal. 

For  reference,  it  is  above  all  price  to  every  prac- 
titioner.— Western  Lancet. 

One  of  the  most  valuable  medical  nublications  of 
the  day — as  a  work  of  reference  it  *„  invaluable. — 
Western  Journal  of  Medicine  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher,  a 
work  for  ready  and  frequent  reference,  one  in  which 
modern  English  medicine  is  exhibited  in  the  most 
advantageous  light. — Medical  Examiner. 

We  rejoice  that  this  work  is  to  be  placed  within 
the  reach  of  the  profession  in  this  country,  it  being 
unquestionably  one  of  very  great  value  to  the  prac- 


DEWEES'S  COMPREHENSIVE  SYSTEM  OF 
MIDWIFERY.  Illustrated  by  occasional  cases 
and  many  engravings.  Twelfth  edition,  with  the 
author's  last  improvements  and  corrections  In 
one  octavo  volume,  extra  cloth ,  of  600  pages.  $3  20. 

DEWEES'S  TREATISE  ON  THE  PHYSICAL 
AND  MEDICAL  TREATMENT  OF  CHILD- 
REN. Tenth  edition.  In  one  volume,  octavo, 
extra  cloth,  548  pages.    $2  80. 

DEWEES'S  TREATISE  ON  THE  DISEASES 
OF  FEMALES.  Tenth  edition.  In  one  volume, 
octavo,  extra  cloth,  532  pages,  with  plates.  $3  00. 


DANA  ON  ZOOPHYTES  AND  CORALS.  In  one 
volume,  imperial  quarto,  extra  cloth,  with  wood- 
cuts. $15  00.  Also,  AN  ATLAS,  in  one  volume, 
imperial  folio,  with  sixty-one  magnificent  colored 
plates.    Bound  in  half  morocco.    $30  00. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER. 
In  one  very  large  and  handsome  octavo  volume,  ex- 
tra cloth,  of  700  pages,  with  300  wood-cuts.  $4  00. 

FRICK  ON  RENAL  AFFECTIONS;  their  Diag- 
nosis and  Pathology.  With  illustrations.  One 
volume,  royal  12mo.,  extra  cloth.    75  cents. 


12 


BLANCHARD   &   LEA'S   MEDICAL 


DUNGLISON    (ROBLEY),    M.  D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

NEW  AND  ENLARGED  EDITION,  Now  Ready. 
MEDICAL  LEXICON;   a  Dictionary  of  Medical  Science,  containing  a  concise 

Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Jurisprudence,  Dentistry, 
&c.  Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for  Officinal,  Empirical,  and  Dietetic 
Preparations,  &c.  With  French  and  other  Synonymes.  Fifteenth  edition,  revised  and  very 
greatly  enlarged.  In  one  very  large  and  handsome  octavo  volume,  of  992  double-columned  pages, 
in  small  type ;  strongly  bound  in  leather,  with  raised  bands.    Price  $4  00. 

JNo  care,  labor,  or  expense  has  been  spared  in  the  preparation  of  this  edition  to  render  it  in  every 
respect  worthy  a  continuance  of  the  very  remarkable  favor  which  it  has  hitherto  enjoyed.  The 
rapid  sale  of  Fifteen  large  editions,  and  the  constantly  increasing  demand,  show  that  it  is  regarded 
by  the  profession  as  the  standard  authority.  Stimulated  by  this  fact,  the  author  has  endeavored  in 
the  present  revision  to  introduce  whatever  might  be  necessary  to  make  it  a  satisfactory  and  desira- 
ble— if  not  indispensable — lexicon,  in  which  the  student  may  search  without  disappointment  for 
every  term  that  has  been  legitimated  in  the  nomenclature  of  the  science.  To  accomplish  this, 
large  additions  have  been  found  requisite,  and  the  extent  of  the  author's  labors  may  be  estimated 
from  the  fact  that  about  Six  Thousand  subjects  and  terms  have  been  introduced  throughout,  ren- 
dering the  whole  number  of  definitions  about  Sixty  Thousand,  to  accommodate  which,  the  num- 
ber of  pages  has  been  increased  by  nearly  a  hundred,  notwithstanding  an  enlargement  in  the  size 
of  the  page.  The  medical  press,  both  in  this  country  and  in  England,  has  pronounced  the  work  in- 
dispensable to  all  medical  students  and  practitioners,  and  the  present  improved  edition  will  not  lose 
that  enviable  reputation. 

The  publishers  have  endeavored  to  render  the  mechanical  execution  worthy  of  a  volume  of  such 
universal  use  in  daily  reference.  The  greatest  care  has  been  exercised  to  obtain  the  typographical 
accuracy  so  necessary  in  a  work  of  the  kind.  By  the  small  but  exceedingly  clear  type  employed, 
an  immense  amount  ol  matter  is  condensed  in  its  thousand  ample  pages,  while  the  binding  will  be 
found  strong  and  durable.  With  all  these  improvements  and  enlargements,  the  price  has  been  kept 
at  the  former  very  moderate  rate,  placing  it  within  the  reach  of  all. 


This  work,  the  appearance  of  the  fifteenth  edition 
of  which,  it  has  become  our  duty  and  pleasure  to 
announce,  is  perhaps  the  most  stupendous  monument 
of  labor  and  erudition  in  medical  literature.  One 
would  hardly  suppose  after  constant  use  of  the  pre- 
ceding editions,  where  we  have  never  failed  to  find 
a  sufficiently  full  explanation  of  every  medical  term, 
that  in  this  edition  "  about  six  thousand  subjects 
and  terms  have  been  added,"  with  a  careful  revision 
and  correction  of  the  entire  work.  It  is  only  neces- 
sary to  announce  the  advent  of  this  edition  to  make 
it  occupy  the  place  of  the  preceding  one  on  the  table 
of  every  medical  man,  as  it  is  withoutdoubt  the  best 
and  most  comprehensive  work  of  the  kind  which  has 
ever  appeared. — Buffalo  Med.  Journ.,  Jan.  1858. 

The  work  is  a  monument  of  patient  research, 
skilful  judgment,  and  vast  physical  labor,  that  will 
perpetuate  the  name  of  the  author  more  effectually 
than  any  possible  device  of  stone  or  metal.  Dr. 
Dunglison  deserves  the  thanks  not  only  of  the  Ame- 
rican profession,  but  of  the  whole  medical  world.— 
North  Am.  Medico-Chir.  Review,  Jan.  1858. 

A  Medical  Dictionary  better  adapted  for  the  wants 
of  the  profession  than  any  other  with  which  we  are 
acquainted,  and  of  a  character  which  places  it  far 
above  comparison  and  competition. — Am.  Journ. 
Med.  Sciences,  Jan.  1858. 

We  need  only  say,  that  the  addition  of  6,000  new 
terms,  with  their  accompanying  definitions,  may  be 
said  to  constitute  a  new  work,  by  itself.  We  have 
examined  the  Dictionary  attentively,  and  are  most 
happy  to  pronounce  it  unrivalled  of  its  kind.  The 
erudition  displayed,  and  the  extraordinary  industry 
which  must  have  been  demanded,  in  its  preparation 
and  perfection,  redound  to  the  lasting  credit  of  its 
author,  and  have  furnished  us  with  a  volume  indis- 
pensable at  the  present  day,  to  all  who  would  find 
themselves  au  niveau  with  the  highest  standards  of 
medical  information. — Boston  Medical  and  Surgical 
Journal,  Dec.  31,  1857. 

Good  lexicons  and  encyclopedic  works  generally, 
are  the  most  labor-savin?  contrivances  which  lite- 
rary men  enjoy;  and  the  labor  which  is  required  to 
produce  them  in  the  perfect  manner  of  this  example 
is  something  appalling  to  contemplate.    The  author 


tells  us  in  his  preface  that  he  has  added  about  six 
thousand  terms  and  subjects  to  this  edition,  which, 
before,  was  considered  universally  as  the  best  work 
of  the  kind  in  any  language. — Silliman's  Journal, 
March,  1858. 

He  has  razed  his  gigantic  structure  to  the  founda- 
tions, and  remodelled  and  reconstructed  the  entire 
pile.  No  less  than  six  thousand  additional  subjects 
and  terms  are  illustrated  and  analyzed  in  this  new 
edition,  swelling  the  grand  aggregate  to  beyond 
sixty  thousand  !  Thus  is  placed  before  the  profes- 
sion a  complete  and  thorough  exponent  of  medical 
terminology,  without  rival  or  possibility  of  rivalry. 
— Nashville  Journ.  of  Med.  and  Surg.,  Jan.  1858. 

It  is  universally  acknowledged,  we  believe,  that 
this  work  is  incomparably  the  best  and  most  com- 
plete Medical  Lexicon  in  the  English  language. 
The  amount  of  labor  which  the  distinguished  author 
has  bestowed  upon  it  is  truly  wonderful,  and  the 
learning  and  research  displayed  in  its  preparation 
are  equally  remarkable.  Comment  and  commenda- 
tion are  unnecessary,  as  no  one  at  the  present  day 
thinks  of  purchasing  any  other  Medical  Dictionary 
than  this.— St.  Louis  Med.  and  Surg.  Journ.,  Jan. 
1858. 

It  is  the  foundation  stone  of  a  good  medical  libra- 
ry, and  should  always  be  included  in  the  first  list  of 
books  purchased  by  the  medical  student.— Am.  Med. 
Monthly,  Jan.  1858. 

A  very  perfect  work  of  the  kind,  undoubtedly  the 
most  perfect  in  the  English  language. — Med.  and 
Surg.  Reporter,  Jan.  1868. 

It  is  now  emphatically  the  Medical  Dictionary  of 
the  English  language,  and  for  it  there  is  no  substi- 
tute.— N.  H.  Med.  Journ.,  Jan.  1858. 

It  is  scarcely  necessary  to  remark  that  any  medi- 
cal library  wanting  a  copy  of  Dunglison's  Lexicon 
must  be  imperfect. — Gin.  Lancet,  Jan.  1858. 

We  have  ever  considered  it  the  best  authority  pub- 
lished, and  the  present  edition  we  may  safely  say  has 
no  equal  in  the  world. — Peninsular  Med.  Journal, 
Jan.  1858. 

The  most  complete  authority  on  the  subject  to  he 
found  in  any  language. —  Va.  Med.  Journal,  Feb.  '58. 


BY  THE  SAME   AUTHOR. 


THE  PRACTICE  OF  MEDICINE.     A  Treatise  on  Special  Pathology  and  The- 

rapeutics.    Third  Edition.    In  two  large  octavo  volumes,  leather,  of  1,500  pages.     $6  25. 


AND    SCIENTIFIC    PUBLICATIONS.  13 

DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

HUMAN    PHYSIOLOGY.      Eighth   edition.      Thoroughly  revised   and  exten- 
sively modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.    In  two  large  and 
handsomely  printed  octavo  volumes,  leather,  of  about  1500  pages.     {Just  Issued,  1856.)      $7  00. 
In  revising  this  work  for  its  eighth  appearance,  the  author  has  spared  no  labor  to  render  it  worthy 
a  continuance  of  the  very  great  favor  which  has  been  extended  to  it  by  the  profession.     The  whole 
contents  have  been  rearranged,  and  to  a  great  extent  remodelled  ;  the  investigations  which  of  late 
years  have  been  so  numerous  and  so  important,  have  been  carefully  examined  and  incorparated, 
and  the  work  in  every  respect  has  been  brought  up  to  a  level  with  the  present  state  of  the  subject. 
The  object  of  the  author  has  been  to  render  it  a  concise  but  comprehensive  treatise,  containing  the 
whole  body  of  physiological  science,  to  which  the  student  and  man  of  science  can  at  all  times  refer 
with  the  certainly  of  finding  whatever  they  are  in  search  of,  fully  presented  in  all  its  aspects;  and 
on  no  former  edition  has  the  author  bestowed  more  labor  to  secure  this  result. 

We  believe  that  it  can  truly  be  said,  no  more  com-  >      The  best  work  of  the  kind   in  the  English  lan- 
plete  repertory  of  facts  upon  the   subject  treated,  j guage. — Silliman's  Journal. 

can  any  where  "be  found.     The  author  has,  moreover,  j      The  present  edition  the  author  has  made  a  perfect 
that  enviable  tact  atjJescription^andUiat  facility  j  mjrror  „f  the  science  as  it  is  at  the  present  hour. 

As  a  work  upon  physiology  proper,  the  science  of 
the  functions  performed  by  the  body,  the  student  will 
find  it  all  he  wishes.— Nashville  Journ.  of  Med. 
Sept.  1856. 

That  he  has  succeeded,  most  admirably  succeeded 
in  his  purpose,  is  apparent  from  the  appearance  of 
an  eighth  edition.  It  is  now  the  great  encyclopaedia 
on  the  subject,  and  worthy  of  a  place  in  every  phy- 
sician's library. — Western  Lancet,  Sept.  1856. 


and  ease  of  expression  which  render  him  peculiarly 
acceptable  to  the  casual,  or  the  studious  reader. 
This  faculty,  so  requisite  in  setting  forth  many 
craver  and  less  attractive  subjects,  lends  additional 
charms  to  one  always  fascinating. — Boston  Med. 
and  Surg.  Journal,  Sept.  1856. 

The  most  complete  and  satisfactory  system  of 
Physiology  in  the  English  language. — Amer.  Med. 
Journal . 


BY  the  same  atjthob.     (Now  Ready.) 

GENERAL    THERAPEUTICS    AND    MATERIA  MEDIC  A;   adapted  for  a 

Medical  Text-book.  With  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies.  Sixth 
Edition,  revised  and  improved.  With  one  hundred  and  ninety-three  illustrations.  In  two  large 
and  handsomely  printed  octavo  vols.,  leather,  of  about  1100  pages.    $6  00. 

Prom  the  Author 's  Preface. 

"  Another  edition  of  this  work  being  called  for,  the  author  has  subjected  it  to  a  thorough  and  careful 
revision.  It  has  been  gratifying  to  him  that  it  has  been  found  so  extensively  useful  by  those  for  whom 
it  was  especially  intended,  as  to  require  that  a  sixth  edition  should  be  issued  in  so  short  a  time  after 
the  publication  of  a  fifth.  Grateful  for  the  favorable  reception  of  the  work  by  the  profession,  he  has 
bestowed  on  the  preparation  of  the  present  edition  all  those  cares  which  were  demanded  by  the 
former  editions,  and.  has  spared  no  pains  to  render  it  a  faithful  epitome  of  General  Therapeutics 
and  Materia  Medica\  The  copious  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies  can- 
not fail,  the  author  conceives,  to  add  materially  to  the  value  of  the  work." 

This  work  is  too  widely  and  too  favorably  known  to  require  more  than  the  assurance  that  the 
author  has  revised  it  with  his  customary  industry,  introducing  whatever  has  been  found  necessary 
to  bring  it  on  a  level  with  the  most  advanced  condition  of  the  subject.  The  number  of  illustrations 
has  been  somewhat  enlarged,  and  the  mechanical  execution  of  the  volumes  will  be  found  to  have 
undergone  a  decided  improvement. 

BY  the  same  author.     (A  new  Edition.) 

NEW  REMEDIES,  WITH  FORMULAE  FOR  THEIR  PREPARATION  AND 

ADMINISTRATION.    Seventh  edition,  with  extensive  Additions.    In  one  very  large  octavo 

volume,  leather,  of  770  pages.     (Just  Issued.)     $3  75.  ' 

Another  edition  of  the  "  New  Remedies"  having  been  called  for,  the  author  has  endeavored  to 
add  everything  of  moment  that  has  appeared  since  the  publication  of  the  last  edition. 

The  chief  remedial  means  which  have  obtained  a  place,  for  the  first  time,  in  this  volume,  either 
owing  to  their  having  been  recently  introduced  into  pharmacology,  or  to  their  having  received  novel 
applications— and  which,  consequently,  belong  to  the  category  of  "  New  Remedies"— are  the  fol- 
lowing : — 

Apiol,  Caffein,  Carbazotic  acid,  Cauterization  and  catheterism  of  the  larynx  and  trachea,  Cedron, 
Cerium,  Chloride  of  bromine,  Chloride  of  iron,  Chloride  of  sodium,  Cinchonicine,  Cod-liver  olein, 
Congelation,  Eau  de  Pagliari,  Galvanic  cautery,  Hydriodic  ether,  Hyposulphite  of  soda  and  silver, 
Inunction,  Iodide  of  sodium,  Nickel,  Permanganate  of  potassa,  Phosphate  of  lime,  Pumpkin,  Quinidia, 
Rennet,  Saccharine  carbonate  of  iron  and  manganese,  Santonin,  Tellurium,  and  Traumaticine. 

The  articles  treated  of  in  the  former  editions  will  be  found  to  have  undergone  considerable  ex- 
pansion in  this,  in  order  that  the  author  might  be  enabled  to  introduce,  as  far  as  practicable,  the 
results  of  the  subsequent  experience  of  others,  as  well  as  of  his  own  observation  and  reflection; 
and  to  make  the  work  still  more  deserving  of  the  extended  circulation  with  which  the  preceding 
editions  have  been  favored  by  the  profession.  By  an  enlargement  of  the  page,  the  numerous  addi- 
tions have  been  incorporated  without  greatly  increasing  the  bulk  of  the  volume. — Preface. 

One  of  the  most  useful  of  the  author's  works.— 
Southern  Medical  and  Surgical  Journal. 

This  elaborate  and  useful  volume  should  be 
found  in  every  medical  library,  for  as  a  book  of  re- 
ference, for  physicians,  it  is  unsurpassed  by  any 
other  work  in  existence,  and  the  double  index  for 
diseases  and  for  remedies,  will  be  found  greatly  to 
enhance  its  value. — New  York  Med.  Gazette. 


The  great  learning  of  the  author,  and  his  remark- 
able industry  in  pushing  his  researches  into  every 
source  whence  information  is  derivable, have  enabled 
him  to  throw  together  an  extensive  mass  of  facts 
and  statements,  accompanied  by  full  reference  to 
authorities;  which  last  feature  renders  the  work 
practically  valuable  to  investigators  who  desire  to 
examine  the  original  papers.— The  American  Journal 
of  Pharmacy. 


14 


BLANCHARD    &    LEA'S    MEDICAL 


ERICHSEN    (JOHN), 

Professor  of  Surgery  in  University  College,  London,  &c. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Surgical 

Injuries,  Diseases,  and  Operations.  Edited  by  John  H.  Brinton,  M.  D.  Illustrated  with 
three  hundred  and  eleven  engravings  on  wood.  In  one  large  and  handsome  octavo  volume,  of 
over  nine  hundred  closely  printed  pages,  leather,  raised  bands.     $4  25. 

rarely  encounter  cases  requiring  surgical  manage- 
ment.— Stethoscope. 

Embracing,  as  will  be  perceived,  the  whole  surgi- 
cal domain,  and  each  division  of  itself  almost  corn- 


It  is,  in  our  humble  judgment,  decidedly  the  best 
book  of  the  kind  in  the  English  language.  Strange 
that  just  such  books  are  notofiener  produced  by  pub- 
lic teachers  of  surgery  in  this  country  and  Great 
Britain  Indeed,  it  is  a  matter  of  great  astonishment, 
but  no  less  true  than  astonishing,  that  of  the  many 
works  on  surgery  republished  in  this  country  within 
the  last  fifteen  or  twenty  years  as  text-books  for 
medical  students,  this  is  the  only  one  that  even  ap- 
proximates to  the  fulfilment  of  the  peculiar  wants  of 
youngmen  just  entering  upon  the  study  of  this  branch 
of  the  profession. —  Western  Jour  .of  Med.  and  Surgery. 

Its  value  is  greatly  enhanced  by  a  very  copious 
well-arranged  index.  We  regard  this  as  one  of  the 
most  valuable  contributions  to  modern  surgery.  To 
one  entering  his  novitiate  of  practice,  we  regard  it 
the  most  serviceable  guide  which  he  can  consult.  He 
will  find  a  fulness  of  detail  leadinghim  through  every 
step  of  the  operation,  and  not  deserting  him  until  the 
final  issue  of  the  case,  is  decided.  For  the  same  rea- 
son we  recommend  it  to  those  whose  routine  of  prac- 
tice lies  in  such  parts  of  the  country  that  they  must 


plete  and  perfect,  each  chapter  full  and  explicit,  each 
subject  faithfully  exhibited,  we  can  only  express  our 
estimate  of  it  in  the  aggregate.  We  consider  it  an 
excellent  contribution  to  surgery,  as  probably  the 
best  single  volume  now  extant  on  the  subject,  and 
with  great  pleasure  we  add  it  to  our  text-books. — 
Nashville  Journal  of  Medicine  and  Surgery. 

Prof.  Erichsen's  work,  for  its  size,  has  not  been 
surpassed;  his  nine  hundred  and  eight  pages,  pro- 
|  fusely  illustrated,  are  rich  in  physiological,  patholo- 
gical, and  operative  suggestions,  doctrines,  details, 
and  processes ;  and  will  prove  a  reliable  resource 
for  information,  both  to  physician  and  surgeon,  in  the 
hour  of  peril. — N.  0.  Med.  and  Surg.  Journal. 

We  are  acquainted  with  no  other  work  wherein 
so  much  good  sense,  sound  principle,  and  practical 
inferences,  stamp  every  page. — American  Lancet. 


ELLIS  (BENJAMIN),  M.D. 
THE   MEDICAL  FORMULARY :   being  a  Collection  of  Prescriptions,  derived 

from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America  and  Europe. 
Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  To  which  is  added 
an  Appendix,  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Ether  and  Chloroform.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.  Tenth  edition, 
revised  and  much  extended  by  Robert  P.  Thomas,  M.  D.,  Professor  of  Materia  Medica  in  the 
Philadelphia  College  of  Pharmacy.  In  one  neat  octavo  volume,  extra  cloth,  of  296  pages.  {Lately 
Issued.)     $1  75. 


After  an  examination  of  the  new  matter  and  the 
alterations,  we  believe  the  reputation  of  the  work 
built  up  by  the  author,  and  the  late  distinguished 
editor,  will  continue  to  flourish  under  the  auspices 
of  the  present  editor,  who  has  the  industry  and  accu- 
racy, and,  we  would  say,  conscientiousness  requi- 
site for  the  responsible  task. — Am.  Jour,  of  P harm. 


It  will  prove  particularly  useful  to  students  and 
young  practitioners,  as  the  most  important  prescrip- 
tions employed  in  modern  practice,  which  lie  scat- 
tered through  our  medical  literature,  are  here  col- 
lected and  conveniently  arranged  for  reference.— 
Charleston  Med.  Journal  and  Review. 


FOWNES  (GEORGE),  PH.  D.,  &c. 
ELEMENTARY    CHEMISTRY;    Theoretical  and  Practical.     With  numerous 

illustrations.     Edited,  with  Additions,  by  Robert  Bridges,  M.  D.    In  one  large  royal  12mo 
volume,  of  over  550  pages,  with  181  wood-cuts 
We  know  of  no  better  text-book,  especially  in  the 
difficult    department  of   organic    chemistry,    upon 


which  it  is  particularly  full  and  satisfactory.  We 
would  recommend  it  to  preceptors  as  a  capital 
"  office  book"  for  their  students  who  are  beginners 
in  Chemistry.  It  is  copiously  illustrated  with  ex- 
cellent wood-cuts,  and  altogether  admirably  "got 
up." — N.  J.  Medical  Reporter. 

A  standard  manual,  which  has  long  enjoyed  the 
reputation  of  embodying  much  knowledge  in  a  small 
space.  The  author  has  achieved  the  difficult  task  of 
condensation  with  masterly  tact.  His  book  is  con- 
cise without  being  dry,  and  brief  without  being  too 
dogmatical  or  general. —  Virginia  Med.  and  Surgical 
Journal. 


In  leather,  $1  50;  extra  cloth,  $1  35. 

The  work  of  Dr.  Fownes  has  long  been  before 


the  public,  and  its  merits  have  been  fully  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.  We  do  not,  of  course,  place  it  in  a  rank 
superior  to  the  works  of  Brande,  Graham,  Turner, 
Gregory,  or  Gmelin,  but  we  say  that,  as  a  work 
for  students,  it  is  preferable  to  any  of  them. — Lon- 
don Journal  of  Medicine. 

A  work  well  adapted  to  the  wants  of  the  student. 
It  is  an  excellent  exposition  of  the  chief  doctrines 
and  facts  of  modern  chemistry.  The  size  of  the  work, 
and  still  more  the  condensed  yet  perspicuous  style 
in  which  it  is  written,  absolve  it  from  the  charges 
very  properly  urged  against  most  manuals  termed 
popular. — Edinburgh  Journal  of  Medical  Science. 


FISKE  FUND  PRIZE  ESSAYS. 
THE  EFFECTS  OF  CLIMATE  ON  TUBERCULOUS  DISEASE.    By  Edwin 

Lee,  M.  R.  C.  S.,  London,  and  THE  INFLUENCE  OF  PREGNANCY"  ON  THE  DEVELOP- 
MENT OF  TUBERCLES.  By  Edward  Warren,  M.  D.,  of  Edenton,  N.  C.  Together  in 
one  neat  octavo  volume,  extra  cloth.    $1  00.     (Just  Ready.) 


FERGUSSON  (WILLIAM),  F.  R.  S., 

Professor  of  Surgery  in  King's  College,  London,  &c. 

A  SYSTEM  OF  PRACTICAL  SURGERY.     Fourth  American,  from  the  third 

and  enlarged  London  edition.    In  one  large  and  beautifully  printed  octavo  volume,  of  about  700 
pages,  with  393  handsome  illustrations,  leather.     $3  00. 

No  work  was  ever  written  which  more  nearly  I      The  addition  of  many  new  pages  makes  this  work 
comprehended  the  necessities  of   the  student  and  |  more  thnnever  indispensable  to  thestudentand  prac- 
practitioner,  and  was  more  carefully  arranged   to    titioner. — Ranking's  Abstract. 
that  single  purpose  than  this. — N.  Y.  Med.  Journal.  | 


AND   SCIENTIFIC    PUBLICATIONS. 


15 


FLINT  (AUSTIN),  M.  D., 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  University  of  Louisville,  &c. 
(An  Important  New  Work.') 

PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OF  DISEASES  AFFECT- 

ING  THE  RESPIRATORY  ORGANS.     In  one  large  and  handsome  octavo  volume,  extra 

cloth,  636  pages.     $3  00. 

We  can  only  state  our  general  impression  of  the 
high  value  of  this  work,  and  cordially  recommend 
it  to  all .  We  regard  it,  in  point  both  of  arrangement 
and  of  the  marked  ability  of  its  treatment  of  the  sub- 
jects, as  destined  to  take  the  first  rank  in  works  of 
this  class.  So  far  as  our  information  extends,  it  has 
at  present  no  equal.  To  the  practitioner,  as  well  as 
the  student,  it  will  be  invaluable  in  clearing  up  the 
diagnosis  of  doubtful  cases,  and  in  shedding  light 
upon  difficult  phenomena. — Buffalo  Med.  Journal. 

This  is  the  most  elaborate  work  devoted  exclu- 
sively to  the  physical  exploration  of  diseases  of  the 
lungs,  with  which  we  are  acquainted  in  the  English 
language.  From  the  high  standing  of  the  author  as 
a  clinical  teacher,  and  his  knowndevotion,  during 
many  years,  to  the  study  of  thoracic  diseases,  much 
was  to  be  expected  from  the  announcement  of  his 
determination  to  embody  in  the  form  of  a  treatise, 


the  results  of  his  study  and  experience.  These.ex- 
pectations  we  are  confident  will  not  be  disappointed . 
For  our  own  part,  we  have  been  favorably  impressed 
by  a  perusal  of  the  book,  and  heartily  recommend  it 
to  all  who  are  desirous  of  acquiring  a  thorough  ac- 
quaintance with  the  means  of*  exploring  the  condi- 
tions of  the  respiratory  organs  by  means  of  auscul- 
tation and  percussion.  —  Boston  Med.  and  Surg. 
Journal. 

A  work  of  original  observation  of  the  highest  merit. 
We  recommend  the  treatise  to  every  one  who  wishes 
to  become  a  correct  auscultator.  Based  to  a  very 
large  extent  upon  cases  numerically  examined,  it 
carries  the  evidence  of  careful  study  and  discrimina- 
tion upon  every  paare.  It  does  credit  to  the  author, 
and,  through  him,  to  the  profession  in  this  country. 
It  is,  what  we  cannot  call  every  book  upon  auscul- 
tation, a  readable  book.— Am.  Jour.  Med.  Sciences. 


NOW  COMPLETE, 
GRAHAM   (THOMAS),   F.  R.  S., 
THE  ELEMENTS   OF   INORGANIC   CHEMISTRY,  including  the  Applica- 
tions of  the  Science  in  the  Arts.   New  and  much  enlarged  edition,  by  Henry  Watts  and  Robert 
Bridges,  M.  D.     Complete  in  one  large  and  handsome  octavo  volume,  of  over  800  very  large 
pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth.  -  $4  00. 

#*%  Part  II.,  completing  the  work  from  p.  431  to  end,  with  Index,  Title  Matter,  &c,  may  be 
had  separate,  cloth  backs  and  paper  sides.     Price  $2  50. 

The  long  delay  which  has  intervened  since  the  appearance  of  the  first  portion  of  this  work,  has 
rendered  necessary  an  Appendix,  embodying  the  numerous  and  important  investigations  and  dis- 
coveries of  the  last  few  years  in  the  subjects  contained  in  Part  I.  This  occupies  a  large  portion 
of  Part  II.,  and  will  be  found  to  present  a  complete  abstract  of  the  most  recent  researches  in  the 
general  principles  of  the  science,  as  well  as  all  details  necessary  to  bring  the  whole  work  thoroughly 
up  to  the  present  time  in  all  departments  of  Inorganic  Chemistry. 

The  great  reputation  which  this  work  has  enjoyed  since  its  first  appearance,  and  its  recognized 
position  in  the  front  rank  of  scientific  treatises,  render  eulogy  unnecessary  to  secure  for  it  imme- 
diate attention  on  the  part  of  those  desiring  to  procure  a  complete  exposition  of  chemical  facts  and 
principles,  either  as\n  introduction  to  the  subject  for  the  student,  or  as  a  work  for  daily  reference 
by  the  practical  chemist. 

Gentlemen  desirous  of  completing  their  copies  of  the  work  are  requested  to  apply  for  Part  11. 
without  delay.     It  will  be  sent  by  mail,  prepaid,  on  receipt  of  the  amount,  $2  50. 


It  is  a  very  acceptable  addition  to  the  library  of 
standard  books  of  every  chemical  student.  Mr. 
Watts,  well  known  as  the  translator  of  the  Cavendish 
Society  edition  of  Gm.elin's  Chemistry,  has  made  in 
the  supplement  an  able  resume  of  the  progress  of 
the  science  since  the  publication  of  the  first  volume. 
It  is  plain  from  the  number  and  importance  of  the 


topics  there  discussed,  that  great  progress  has  been 
made  in  the  interval,  both  in  chemical  physics  and 
in  general  inorganic  chemistry.  No  reader  of  Eng- 
lish works  on  this  science  can  afford  to  be  without 
this  edition  of  Prof.  Graham's  Elements. — Silliman's 
Journal,  March,  1858. 


GRIFFITH  (ROBERT  E.),  M.  D.,  &c. 
A  UNIVERSAL  FORMULARY,  containing  the  methods  of  Preparing  and  Ad- 
ministering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceu- 
tists. Second  Edition,  thoroughly  revised,  with  numerous  additions,  by  Robert  P.  Thomas, 
M.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large  and 
handsome  octavo  volume,  extra  cloth.,  of  650  pages,  double  columns.  (Just  Isszted.)  $3  00;  or 
bound  in  sheep,  $3  25. 


nistering  medicines  that  can  be  desired  by  the  physi- 
cian and  pharmaceutist.—  Western  Lancet. 

The  amountof  useful,  every-day  matter. for  a  prac- 
ticing  physician,  is  really  immense. — Boston  Med. 
and  Surg.  Journal. 

We  predict  a  great  sale  for  this  work,  and  we  espe- 
cially recommend  it  to  all  medical  teachers. — Rich' 


It  was  a  work  requiring  much  perseverance,  and 
when  published  was  looked  upon  as  by  far  the  best 
work  of  its  kind  that  had  issued  from  the  American 
press.  Prof  Thomas  has  certainly  "improved,"  as 
well  as  added  lothis  Formulary,  and  has  rendered  it 
additionally  deserving  of  the  confidence  of  pharma- 
ceutists and  physicians.— Am.  Journal  of  Pharmacy. 

We  are  happy  to  announce  a  new  and  improved 
edition  of  this,  one  of.  the  most  valuable  and  useful 
works  that  have  emanated  from  an  American  pen. 
It  would  do  credit  to  any  country,  and  will  be  found 
of  daily  usefulness  to  practitioners  of  medicine;  it  is 
better  adapted  to  their  purposes  than  the  dispensato- 
ries.— Southern  Med.  and  Surg.  Journal. 

It  is  one  of  the  most  useful  books  a  country  practi- 
tioner can  possibly  have  in  his  possession.— Medical 
Chronicle. 

This  is  a  work  of  six  hundred  and  fifty-one  pages, 
embracing  all  on  the  subject  of  preparing  and  admi- 

BY   THE   SAME   AUTHOR. 

MEDICAL  BOTANY ;  or,  a  Description  of  all  the  more  important  Plants  used 
in  Medicine,  and  of  their  Properties,  Uses,  and  Modes  of  Administration.  In  one  large  octavo 
volume,  extra  cloth,  of  704  pages,  handsomely  printed,  with  nearly  350  illustrations  on  wood.  $3  00. 


mond  Stethoscope. 

This  edition  of  Dr.  Griffith's  work  has  been  greatly 
improved  by  the  revision  and  ample  additions  of  Dr. 
Thomas,  and  is  now,  we  believe,  one  of  the  most 
complete  works  of  its  kind  in  any  language.  The 
addition!  amount  to  about  seventy  pages,  and  no 
effort  has  been  spared  to  include  in  them  all  the  re- 
cent improvements  which  have  been  published  in 
medical  journals,  and  systematic  treatises.  A  work 
of  this  kind  appears  to  us  indispensable  lo  the  physi- 
cian, and  there  is  none  we  can  more  cordially  recom- 
mend.— N.  Y.  Journal  of  Medicine. 


16 


BLANCHARD   &   LEA'S   MEDICAL 


GROSS  (SAMUEL  D.),    M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  &c. 

New  Edition  (Now  Ready.) 
ELEMENTS  OF  PATHOLOGICAL  ANATOMY.     Third  edition,  thoroughly 

revised  and  greatly  improved.     In  one  large  and  very  handsome  octavo  volume,  with  about  three 

hundred  and  fifty  beautiful  illustrations,  of  which  a  large  number  are  from  original  drawings. 

Price  in  extra  cloth,  $4  75;  leather,  raised  bands,  $5  25. 

The  very  rapid  advances  in  the  Science  of  Pathological  Anatomy  during  the  last  few  years  have 
rendered  essential  a  thorough  modification  of  this  work,  with  a  view  of  making  it  a  correct  expo- 
nent of  the  present  state  of  the  subject.  The  very  careful  manner  in  which  this  task  has  been 
executed,  and  the  amount  of  alteration  which  it  has  undergone,  have  enabled  the  author  to  say  that 
"  with  the  many  changes  and  improvements  now  introduced,  the  work  may  be  regarded  almost  as 
a  new  treatise,"  while  the  efforts  of  the  author  have  been  seconded  as  regards  the  mechanical 
execution  of  the  volume,  rendering  it  one  of  the  handsomest  productions  of  the  American  press. 
A  very  large  number  of  new  and  beautiful  original  illustrations  have  been  introduced,  and  the  work, 
it  is  hoped,  will  fully  maintain  the  reputation  hitherto  enjoyed  by  it  of  a  complete  and  practical  ex- 
position of  its  difficult  and  important  subject. 

We  most  sincerely  congratulate  the  author  on  the  .      We  have  been  favorably  impressed  with  the  gene 


successful  manner  in  which  he  has  accomplished  his 
proposed  object.  His  book  is  most  admirably  cal- 
culated to  fill  up  a  blank  which  has  long  been  felt  to 
exist  in  this  department  of  medical  literature,  and 
as  such  must  become  very  widely  circulated  amongst 
all  classes  of  the  profession.  —  Dublin  Quarterly 
Journ.  of  Med.  Science,  Nov.  1857. 


ral  manner  in  which  Dr.  Gross  has  executed  his  task 
of  affording1  a  comprehensive  digest  of  the  present 
state  of  the  literature  of  Pathological  Anatomy,  and 
have  much  pleasure  in  recommending  his  work  to 
our  readers,  as  we  believe  one  well  deserving  of 
dilisrent  perusal  and  careful  study. — Montreal  Med. 
Chron.,  Sept.  1857. 


BY  THE  SAME   AUTHOR. 

A   PRACTICAL    TREATISE   ON   THE    DISEASES,    INJURIES,  AND 

MALFORMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND,  AND 
THE  URETHRA.  Second  Edition,  revised  and  much  enlarged,  with  one  hundred  and  eighty- 
four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine  hundred  pages. 
In  leather,  raised  bands,  $5  25 ;  extra  cloth,  $4  75. 


A  volume  replete  with  truths  and  principles  of  the 
utmost  value  in  the  investigation  of  these  diseases. — 
American  Medical  Journal . 

On  the  appearance  of  the  first  edition  of  this  work, 
the  leading  English  medical  review  predicted  that  it 
would  have  a  "  permanent  place  in  the  literature  of 
surgery  worthy  to  rank  with  the  best  works  of  the 
present  age."  This  prediction  has  been  amply  ful- 
filled. Dr.  Gross's  treatise  has  been  found  to  sup- 
ply completely  the  want  which  has  been  felt  ever 
since  the  elevation  of  surgery  to  the  rank  of  a  science, 
of  a  good  practical  treatise  on  the  diseases  of  the 
bladder  and  its  accessory  organs.  Philosophical  in 
its  design,  methodical  in  its  arrangement,  ample  and 


sound  in  its  practical  details,  it  may  in  truth  be  said 
to  leave  scarcely  anything  to  be  desired  on  so  im- 
portant a  subject,  and  with  the  additions  and  modi- 
fications resulting  from  future  discoveries  and  im- 
provements, it  will  probably  remain  one  of  the  most 
valuable  works  on  this  subject  so  long  as  the  science 
of  medicine  shall  exist. — Boston  Med.  and  Surg. 
Journal. 

Whoever  will  peruse  the  vast  amount  of  valuable 
practical  information  it  contains,  and  which  we 
have  been  unable  even  to  notice,  will,  we  think, 
agree  with  us,  that  there  is  no  work  in  the  English 
language  which  can  make  any  just  pretensions  to 
be  its  equal. — N.  Y.  Journal  of  Medicine. 


BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIR-PAS- 

SAGES.     In  one  handsome  octavo  volume,  extra  cloth,  with  illustrations,    pp.  468.     $2  75. 

A  very  elaborate  work.  It  is  a  complete  summary  i  conclude  by  recommending  it  to  our  readers,  fully 
of  the  whole  subject,  and  will  be  a  useful  book  of  j  persuaded  that  its  perusal  will  afford  them  much 
reference. — British  and  Foreign  Medico-Chirurg.  practical  information  well  conveyed,  evidently  de- 
Review .  j  rived  from  considerable  experience  and  deduced  from 

A  highly  valuable  book  of  reference  on  a  most  im-  an  ample  collection  of  facts.  —  Dublin  Quarterly 
portant  subject  in  the  practice  of  medicine.    We  I  Journal,  May,  1855. 

by  the  same  author.     (Preparing-.) 

A  SYSTEM  OF  SURGERY ;  Diagnostic,  Pathological,  Therapeutic,  and  Opera- 
tive.   With  very  numerous  engravings  on  wood. 


GLUGE  (GOTTLIEB),  M.  D., 

Professor  of  Physiology  and  Pathological  Anatomy  in  the  University  of  Brussels,  &c. 

AN  ATLAS  OF  PATHOLOGICAL  HISTOLOGY.     Translated,  with  Notes 

and  Additions,  by  Joseph  Leidy,  M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylva- 
nia. In  one  volume,  very  large  imperial  quarto,  extra  cloth,  with  320  figures,  plain  and  colored, 
on  twelve  copperplates.     $5  00. 


GARDNER'S  MEDICAL  CHEMISTRY,  for  the 
use  of  Students  and  the  Profession.  In  one  royal 
l2mo.  vol.,  ex.  cloth,  pp.  396,  with  illustrations. 
81  00. 

HARRISON'S  ESSAY  TOWARDS  A  CORRECT 
THEORY  OF  THE  NERVOUS  SYSTEM.  In 
one  octavo  volume,  leather,  292  pages.    81  50. 


HUGHES'  CLINICAL  INTRODUCTION  TO 
THE  PRACTICE  OF  AUSCULTATION  AND 
OTHER  MODES  OF  PHYSICAL  DIAGNOSIS, 
IN  DISEASES  OF  THE  LUNGS  AND  HEART. 

Second  American,  from  the  second  London  edition. 
1  vol.  royal  12mo.,  ex.  cloth,  pp.  304.    81  00. 

HUNTER'S  COMPLETE  WORKS,  in  4  vols. 
8vo.,  leather,  with  plates.     810. 


AND    SCIENTIFIC    PUBLICATIONS. 


17 


HOBLYN  (RICHARD  D.),  M.  D. 
A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND  THE 

COLLATERAL  SCIENCES.  By  Richard  D.  Hoblyn,  A.  M.,  &c  A  new  American  edi- 
tion. Revised,  with  numerous  Additions,  by  Isaac  Hays,  M.  L\,  editor  of  the  "American 
Journal  of  the  Medical  Sciences."  In  one  large  royal  12mo.  volume,  leather,  of  over  500  double 
columned  pages.     (Just  Issued^  1856.)    $1  50. 


If  the  frequency  with  which  we  have  referred  to 
this  volume  since  its  reception  from  the  publisher, 
two  or  three  weeks  ago,  be  any  criterion  for  the 
future,  the  binding  will  soon  have  to  be  renewed,  even 
with  careful  handling.  We  find  that  Dr.  Hays  has 
done  the  profession  great  service  by  his  careful  and 
industrious  labors.  The  Dictionary  has  thus  become 
eminently  suited  to  our  medical  brethren  in  this 
country.  The  additions  by  Dr.  Hays  are  in  brackets, 
and  we  believe  there  is  not  a  single  page  but  bears 
these  insignia ;  in  every  instance  which  we  have  thus 
far  noticed,  the  additions  are  really  needed  and  ex- 
ceedingly valuable.  We  heartily  commend  the  work 
to  all  who  wish  to  be  au  courant  in  medical  termi- 
nology.— Boston  Med.  and  Surg.  Journal. 

To  both  practitioner  and  student,  we  recommend 
this  dictionary  as  being  convenient  in  size,  accurate 
in  definition,  and  sufficiently  full  and  complete  for 
ordinary  consultation. — Charleston  Med.  Journ.  and 
Review. 

Admirably  calculated  to  meet  the  wants  of  the 
practitioner  or  student,  who  has  neither  the  means 


nor  desire  to  procure  a  larger  work.  —  American 
Lancet. 

Hoblyn  has  always  been  a  favorite  dictionary,  and 
in  its  present  enlarged  and  improved  form  will  give 
greater  satisfaction  than  ever.  The  American  editor, 
Dr.  Hays,  has  made  many  very  valuable  additions. 
— N.  J.  Med.  Reporter. 

To  supply  the  want  of  the  medical  reader  arising 
from  this  cause,  we  know  of  no  dictionary  better 
arranged  and  adapted  than  the  one  bearing  the  above 
title.  It  is  not  encumbered  with  the  obsolete  terms 
of  a  bygone  age,  but  it  contains  all  that  are  now  in 
use  ;  embracing  every  department  of  medical  science 
down  to  the  very  latest  date.  The  volume  is  of  a 
convenient  size  to  be  used  by  the  medical  student, 
and  yet  large  enough  to  make  a  respectable  appear- 
ance in  the  library  of  a  physician. — Western  Lancet. 

Hoblyn's  Dictionary  has  long  been  a  favorite  with 
us.  It  is  the  best  book  of  definitions  we  have,  and 
ought  always  to  be  upon  the  student's  table. — 
Southern  Med.  and  Surg.  Journal. 


HOLLAND  (SJR    HENRY),    BART.,    M.  D.,  F.  R.  S., 

Physician  in  Ordinary  to  the  Queen  of  England,  &c. 

MEDICAL  NOTES  AND  REFLECTIONS.     From  the  third  London  edition. 

In  one  handsome  octavo  volume,  extra  cloth,    (Now  Ready.)    $3  00. 

As  the  work  of  a  thoughtful  and  observant  physician,  embodying  the  results  of  forty  years'  ac- 
tive professional  experience,  on  topics  of  the  highest  interest,  this  volume  is  commended  to  the 
American  practitioner  as  well  worthy  his  attention.  Few  will  rise  from  its  perusal  without  feel- 
ing their  convictions  strengthened,  and  armed  with  new  weapons  for  the  daily  struggle  with 
disease. 


\  HABERSHON  (S.  O.),  M.  D., 

Assistant  Physician  to  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Guy's  Hospital,  &c. 

PATHOLOGICAL   AND   PRACTICAL  OBSERVATIONS  ON  DISEASES 

OF  THE  ALIMENTARY  CANAL,  OESOPHAGUS,  STOMACH,  CAECUM,  AND  INTES- 
TINES. With  illustrations  on  wood.  In  one  handsome  octavo  volume.  (Republishing  in  the 
Medical  News  and  Library  for  1858.) 


HORNER  (WILLIAM  E.),  M.  D.? 

Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

SPECIAL   ANATOMY   AND    HISTOLOGY.    Eighth  edition.     Extensively 

revised  and  modified.      In  two  large  octavo  volumes,  extra  cloth,  of  more  than  one  thousand 
pages,  handsomely  printed,  with  over  three  hundred  illustrations.    $6  00. 


HAMILTON   (FRANK   H.),   M.  D., 

Professor  of  Surgery,  in  Buffalo  Medical  College,  &c. 

A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS. 

o«tavo  volume,  with  numerous  illustrations.     (Preparing.) 


In  one  handsome 


JONES  (T.   WHARTON),   F.  R.  S., 

Professor  of  Ophthalmic  Medicine  and  Surgery  in  University  College,  London,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF   OPHTHALMIC    MEDICINE 

AND  SURGERY.  With  one  hundred  and  ten  illustrations.  Second  American  from  the  second 
and  revised  London  edition,  with  additions  by  Edward  Hartshorne,  M.  D.,  Surgeon  to  Wills' 
Hospital,  &c.     In  one  large,  handsome  royal  12mo.  volume,  extra  cloth,  of  500  pages.    $1  50. 


We  are  confident  that  the  reader  will  find,  on 
perusal,  that  the  execution  of  the  work  amply  fulfils 
the  promise  of  the  preface,  and  sustains,  in  every 
point,  the  already  high  reputation  of  the  author  as 
an  ophthalmic  surgeon  as  well  as  a  physiologist 
and  pathologist.  The  book  is  evidently  the  result 
of  much  labor  and  research,  and  has  been  written 
With  the  greatest  care  and  attention;  it  possesses 
that  best  quality  which  a  general  work,  like  a  sys- 
tem or  manual  can  show,  viz  :  the  quali  ty  of  having 
all  the  materials  whencesoever  derived,  so  thorough- 


ly wrought  up,  and  digested  in  the  author's  mind, 
as  to  come  forth  with  the  freshness  and  impressive- 
ness  of  an  original  production.  We  entertain  little 
doubt  that  this  book  will  become  what  its  author 
hoped  it  might  become,  a  manual  for  daily  reference 
and  consultation  by  the  student  and  the  general  prac- 
titioner. The  work  is  marked  by  that  correctness, 
clearness,  and  precision  of  style  which  distinguish 
all  the  productions  of  the  learned  author. — British 
and  For.  Med.  Review. 


IS 


LANCHARD    &    LEA'S    MEDICAL 


JONES  (C. 


HANDFIELD),  F.  R.  S.,  &  EDWARD  H.  SIEVEKING,  M 

Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hospital,  London. 


A  MANUAL  OF  PATHOLOGICAL  ANATOMY.     First  American  Edition, 

Revised.    "With  three  hundred  and  ninety-seven  handsome  wood  engravings.    In  one  large  and 
beautiful  octavo  volume  of  nearly  750  pages,  leather.    $3  75. 

present  condition  of  pathological  anatomy.    In  this 


As  a  concise  text-book,  containing,  in  a  condensed 
form,  a  complete  outline  of  what  is  known  in  the 
domain  of  Pathological  Anatomy,  it  is  perhaps  the 
best  work  in  the  English  language.  Its  great  merit 
consists  in  its  completeness  and  brevity,  and  in  this 
respect  it  supplies  a  great  desideratum  in  our  lite- 
rature. Heretofore  the  student  of  pathology  was 
obliged  to  glean  from  a  great  number  of  monographs, 
and  the  field  was  so  extensive  that  but  few  cultivated 
it  with  any  degree  of  success.  As  a  simple  work 
of  reference,  therefore,  it  is  of  great  value  to  the 
student  of  pathological  anatomy,  and  should  be  in 
every  physician's  library.— Western  Lancet. 

In  offering  the  above  titled  work  to  the  public,  the 
authors  have  not  attempted  to  intrude  new  views  on 
their  professional  brethren,  but  simply  to  lay  before 
them,  what  has  long  been  wanted,  an  outline  of  the 


they  have  been  completely  successful.  The  work  is 
one  of  the  best  compilations  which  we  have  ever 
perused. — Charleston  Medical  Journal  and  Review. 

We  urge  upon  our  readers  and  the  profession  gene- 
rally the  importance  of  informing  themselves  in  re- 
gard to  modern  views  of  pathology,  and  recommend 
to  them  to  procure  the  work  before  us  as  the  best 
means  of  obtaining  this  information. — Stethoscope. 

From  the  casual  examination  we  have  given  we 
are  inclined  to  regard  it  as  a  text-book,  plain,  ra- 
tional, and  intelligible,  such  a  book  as  the  practical 
man  needs  for  daily  reference.  For  this  reason  it 
will  be  likely  to  be  largely  useful,  as  it  suits  itself 
to  those  busy  men  who  have  little  time  for  minute 
investigation,  and  prefer  a  summary  to  an  elaborate 
treatise. — Buffalo  Medical  Journal. 


KIRKES  (WILLIAM  SENHOUSE),   M.D., 

Demonstrator  of  Morbid  Anatomy  at  St.  Bartholomew's  Hospital,  &c. 

A    MANUAL    OF    PHYSIOLOGY.      A  new  American,  from  the  third  and 

improved  London  edition.    With  two  hundred  illustrations.     In  one  large  and  handsome  royal 

12mo.  volume,  leather,     pp.  586.     $2  00.     (Now  Ready,  1857.) 

In  again  passing  this  work  through  his  hands,  the  author  has  endeavored  to  render  it  a  correct 
exposition  of  the  present  condition  of  the  science,  making  such  alterations  and  additions  as  have 
been  dictated  by  further  experience,  or  as  the  progress  of  investigation  has  rendered  desirable.  In 
every  point  of  mechanical  execution  the  publishers  have  sought  to  make  it  superior  to  former  edi- 
tions, and  at  the  very  low  price  at  which  it  is  offered,,  it  will  be  found  one  of  the  handsomest  and 
cheapest  volumes  before  the  profession. 

In  making  these  improvements,  care  has  been  exercised  not  unduly  to  increase  its  size,  thus 
maintaining  its  distinctive  characteristic  of  presenting  within  a  moderate  compass  a  clear  and  con- 
nected view  of  its  subjects,  sufficient  for  the  wants  of  the  student. 


This  is  a  new  and  very  much  improved  edition  of 
Dr.  Kirkes'  well-known  Handbook  of  Physiology. 
Originally  constructed  on  the  basis  of  the  admirable 
treatise  of  Miller,  it  has  in  successive  editions  de- 
veloped itself  into  an  almost  original  work,  though 
no  change  has  been  made  in  the  plan  or  arrangement. 
It  combines  conciseness  with  completeness,  and  is, 
therefore,  admirably  adapted  for  consultation  by  the 
busy  practitioner. — Dublin  Quarterly  Journal,  Feb. 
1857. 

Its  excellence  is  in  its  compactness,  its  clearness, 
and  its  carefully  cited  authorities.  It  is  the  most 
convenient  of  text-books.  These  gentlemen,  Messrs. 
Kirkes  and  Paget,  have  really  an  immense  talent  for 
silence,  which  is  not  so  common  or  so  cheap  as  prat- 
ing people  fancy.  They  have  the  gift  of  telling  us 
what  we  want  to  know,  without  thinking  it  neces- 
sary to  tell  us  all  they  know. — Boston  Med.  and 
Surg.  Journal,  May  14,  1857. 


One  of  the  very  best  handbooks  of  Physiology  we 
possess — presenting  just  such  an  outlina  of  the  sci- 
ence, comprising  an  account  of  its  leading  facts  and 
generally  admitted  principles,  as  the  student  requires 
during  his  attendance  upon  a  course  of  lectures,  or 
for  reference  whilst  preparing  for  examination. — 
Am.  Medical  Journal. 

We  need  only  say,  that,  without  entering  into  dis- 
cussions of  unsettled  questions,  it  contains  all  the 
recent  improvements  in  this  department  of  medical 
science.  For  the  student  beginning  this  study,  and 
the  practitioner  who  has  but  leisure  to  refresh  his 
memory,  this  book  is  invaluable,  as  it  contains  all 
that  it  is  important  to  know,  without  special  details, 
which  are  read  with  interest  only  by  those  who 
would  make  a  specialty,  or  desire  to  possess  a  criti«- 
cal  knowledge  of  the  subject.— Charleston  Medical 
Journal. 


KNAPP'S  TECHNOLOGY ;  or,  Chemistry  applied 
to  the  Arts  and  to  Manufactures.  Edited,  with 
numerous  Notes  and  Additions,  by  Dr.  Edmund 
Ronalds  and  Dr.  Thomas  Richardson.  First 
American  edition,  with  Notes  and  Additions,  by 
Prof.  Waltek  R.  Johnson.     In  two  handsome 


octavo  volumes,  extra  cloth,  with  about  500  wood- 
engravings.  $6  00. 
LALLEMAND  ON  SPERMATORRHOEA.  Trans- 
lated and  edited  byHENKY  J.  McDottgal.  In  one 
volume,  octavo,  extra  cloth,  320  pages.  Second 
American  edition.    $1  75. 


LUDLOW  (J.   LJ,   M.  D. 
A  MANUAL   OF    EXAMINATIONS   upon   Anatomy,   Physiology,   Surgery, 

Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and  Therapeutics.  To 
which  is  added  a  Medical  Formulary.  Designed  for  Students  of  Medicine  throughout  the  United 
States.  Third  edition,  thoroughly  revised  and  greatly  extended  and  enlarged.  With  three 
hundred  and  seventy  illustrations.  In  one  large  and  handsome  royal  12mo.  volume,  leather,  of 
over  800  closely  printed  pages.     (Now  Ready.)    $2  50. 

The  great  popularity  of  this  volume,  arid  the  numerous  demands  for  it  during  the  two  years  in  which 
it  has  been  out  of  print,  have  induced  the  author  in  its  revision  to  spare  no  pains  to  render  it  a 
correct  and  accurate  digest  of  the  most  recent  condition  of  all  the  branches  of  medical  science.  In 
many  respects  it  may,  therefore,  be  regarded  rather  as  a  new  book  than  a  new  edition,  an  entire 
section  on  Physiology  having  been  added,  as  also  one  on  Organic  Chemistry,  and  many  portions 
having  been  rewritten.  A  very  complete  series  of  illustrations  has  been  introduced,  and  every 
care  has  been  taken  in  the  mechanical  execution  to  render  it  a  convenient  and  satisfactory  book  for 
study  or  reference. 

The  arrangement  of  the  volume  in  the  form  of  question  and  answer  renders  it  especially  suited 
for  the  office  examination  of  students  and  for  those  preparing  for  graduation. 


inn 

during  the  hours  spent  in  the  lecture  room,  or  to  re- 
fresh, at  a  glance,  his  memory  of  the  various  topics 


whom  he  is  compelled  to  listen. 
May,  1857. 


-Western  Lancet. 


AND    SCIENTIFIC    PUBLICATIONS.  19 

LEHMANN   (C.  G.) 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edition  by 
George  E.  Day,  M.  D.,  F.  R.  S.,  &c,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of  Chemistry 
in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations  selected  from 
Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Complete  in  two  large 
and  handsome  octavo  volumes,  extra  cloth,  containing  1200  pages,  with  nearly  two  hundred  illus- 
trations.    {Just  Issued.)     $6  00. 

This  great  work,  universally  acknowledged  as  the  most  complete  and  authoritative  exposition  of 
the  principles  and  details  of  Zoochemistry,  in  its  passage  through  the  press,  has  received  from 
Professor  Rogers  such  care  as  was  necessary  to  present  it  in  a  correct  and  reliable  form.  To  such 
a  work  additions  were  deemed  superfluous,  but  several  years  having  elapsed  between  the  appear- 
ance in  Germany  of  the  first  and  last  volume,  the  latter  contained  a  supplement,  embodying  nume- 
rous corrections  and  additions  resulting  from  the  advance  of  the  science.  These  have  all  been  incor- 
porated in  the  text  in  their  appropriate  places,  while  the  subjects  have  been  still  further  elucidated  by 
the  insertion  of  illustrations  from  the  Atlas  of  Dr.  OttoFunke.  With  the  view  of  supplying  the  student 
with  the  means  of  convenient  comparison,  a  large  number  of  wood-cuts,  from  works  on  kindred 
subjects,  have  also  been  added  in  the  form  of  an  Appendix  of  Plates.  The  work  is,  therefore,  pre- 
sented as  in  every  way  worthy  the  attention  of  all  who  desire  to  be  familiar  with  the  modern  facts 
and  doctrines  of  Physiological  Science. 

it  treats. — Edinburgh  Monthly  Journal  of  Medical 
Science. 

Already  well  known  and  appreciated  by  the  scien- 
tific world,  Professor  Lehmann's  great  work  re- 
quires no  laudatory  sentences,  as,  under  a  new  garb, 
it  is  now  presented  to  us.  The  little  space  at  our 
command  would  ill  suffice  to  set  forth  even  a  small 
portion  of  its  excellences. — Boston  Med.  and  Surg. 
Journal,  Dec.  1855. 


The  most  important  contribution  as  yet  made  to 
Physiological  Chemistry. — Am.  Journal  Med.  Sci- 
ences, Jan. 1856. 

The  present  volumes  belong  to  the  small  class  of 
medical  literature  which  comprises  elaborate  works 
of  the  highest  order  of  merit. — Montreal  Med.  Chron- 
icle, Jan. 1856. 

The  work  of  Lehmann  stands  unrivalled  as  the 
most  comprehensive  book  of  reference  and  informa- 
tion extant  on  every  branch  of  the  subject  on  which 

BY  THE  SAME  AUTHOR.      {Just  Issued,  1856.) 

MANUAL  OF  CHEMICAL   PHYSIOLOGY.      Translated  from  the  German, 

with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory  Essay  on  Vital 
Force,  by  Samuel  Jackson,  M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  University  of 
Pennsylvania.  With  illustrations  on  wood.  In  one  very  handsome  octavo  volume,  extra  cloth, 
of  336  pages.    $2  25. 

From.  Prof.  Jackson's  Introductory  Essay. 

In  adopting  the  handbook  of  Dr.  Lehmann  as  a  manual  of  Organic  Chemistry  for  the  use  of  the 
students  of  the  University,  and  in  recommending  his  original  work  of  Physiological  Chemistry 
for  their  more^mature  studies,  the  high  value  of  his  researches,  and  the  great  weight  of  his  autho- 
rity in  that  important  department  of  medical  science  are  fully  recognized. 

densed  form,  the  positive  facts  of  Physiological 


The  present  volume  will  be  a  very  convenient  one 
for  students,  as  offering  a  brief  epitome  of  the  more 
elaborate  work,  and  as  containing,  in  a  very  con- 


Chemistry. — Am.  Journal  Med.  Sciences,  April,  1856. 


LAWRENCE  (W.),   F.  R.  S.,  &.C. 
A  TREATISE    ON   DISEASES    OF   THE   EYE.     A    new  edition,  edited, 

with  numerous  additions,  and  243  illustrations,  by  Isaac  Hays,  M.  D.,  Surgeon  to  Will's  Hospi- 
tal, &c.     In  one  very  large  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leather 
with  raised  bands.     $5  00. 
This  admirable  treatise— the  safest  guide  and  most  1  octavo  pages— has  enabled  both  author  and  editor  to 


comprehensive  work  of  reference,  which  is  within 
the  reach  of  the  profession. — Stethoscope. 

This  standard  text-book  on  the  department  of 
which  it  treats,  has  not  been  superseded,  by  any  or 
all  of  the  numerous  publications  on  the  subject 
heretofore  issued.  Nor  with  the  multiplied  improve- 
ments of  Dr.  Hays,  the  American  editor,  is  it  at  all 
likely  that  this  great  work  will  cease  to  merit  the 
confidence  and  preference  of  students  or  practition 


do  justice  to  all  the  details  of  this  subject,  and  con- 
dense in  this  single  volume  the  present  state  of  our 
knowledge  of  the  whole  science  in  this  department, 
whereby  its  practical  value  cannot  be  excelled.  We 
heartily  commend  it,  especially  as  a  book  of  refer- 
ence, indispensable  in  every  medical  library.  The 
additions  of  the  American  editor  very  greatly  en- 
hance the  value  of  the  work,  exhibiting  the  learning 
and  experience  of  Dr.  Hays,  in  the  light  in  which  he 
ought  to  be  held,  as  a  standard  authority  on  all  sub- 
ers.    Its  ample  extent — nearly  one  thousand  large  j  jects  appertaining  to  this  specialty .—N.Y.  Med.  Gaz. 


HANDBOOKS    OF    NATURAL    PHILOSOPHY    AND    ASTRONOMY. 

Revised,  with  numerous  Additions,  by  the  American  editor.  First  Course,  containing  Mecha- 
nics, Hydrostatics,  Hydraulics,  Pneumatics,  Sound,  and  Optics.  In  one  large  royal  12mo. 
volume,  of  750  pages,  with  424  wood-cuts.  $1  75.  Second  Course,  containing  Heat,  Electricity, 
Magnetism,  and  Galvanism,  one  volume,  large  royal  12mo.,  of  450  pages,  with  250  illustrations. 
$1  25.  Third  Course  {now  ready),  containing  Meteorology  and  Astronomy,  in  one  large  volume, 
royal  12mo.  of  nearly  800  pages,  with  37  plates  and  200  wood-cuts.     $2  00. 

*_ 

LAYCOCK  (THOMAS),   M .  D.,   F.  R.  S.  E., 

Professor  of  Practical  and  Clinical  Medicine  in  the  University  of  Edinburgh,  &c. 

LECTURES    ON   THE    PRINCIPLES    AND   METHODS    OF    MEDICAL 

OBSERVATION  AND  RESEARCH.  For  the  Use  of  Advanced  Students  and  Junior  Prac- 
titioners.  In  one  very  neat  royal  12mo.  volume,  extra  cloth.  Price  $1  00.  {Just  Published,  1857.) 


2Q 


BLANCHARD    &    LEA'S   MEDICAL 


LA  ROCHE  (R.),  M.  D.,  &c. 
YELLOW  FEVER,  considered  in  its  Historical,  Pathological,  Etiological,  and 
Therapeutical  "Relations.  Including  a  Sketch  of  the  Disease  as  it  has  occurred  in  Philadelphia 
from  1699  to  1854,  with  an  examination  of  the  connections  between  it  and  the  fevers  known  under 
the  same  name  in  other  parts  of  temperate  as  well  as  in  tropical  regions.  In  two  large  and 
handsome  octavo  volumes  of  nearly  1500  pages,  extra  cloth.  $7  00. 
From  Professor  S.  H.  Dickson,  Charleston,  S.  C, 

September  18,  1855. 
A  monument  of  intelligent  and  well  applied  re- 
search, almost  without  example.  It  is,  indeed,  in 
itself,  a  large  library,  and  is  destined  to  constitute 
the  special  resort  as  a  book  of  reference,  in  the 
subject  of  which  it  treats,  to  all  future  time. 


arduous  research  and  careful  study,  and  the  result 
is  such  as  will  reflect  the  highest  honor  upon  thfe 
author  and  our  country.— Southern  Med.  and  Surg. 
Journal. 

The  genius  and  scholarship  of  this  great  physicitm 
could  not  have  been  better  employed  than  in  the 
erection  of  this  towering  monument  to  his  own  fame, 
and  to  the  glory  of  the  medical  literature  of  his  own 
country.  It  is  destined  to  remain  the  great  autho- 
rity upon  the  subject  of  Yellow  Fever.  The  student 
and  physician  will  find  in  these  volumes  a  risum.6 
of  the  sum  total  of  the  knowledge  of  the  world  upon 
the  awful  scourge  which  they  so  elaborately  discuss. 
The  style  is  so  soft  and  so  pure  as  to  refresh  and  in- 
vigorate the  mind  while  absorbing  the  thoughts  of 
the  gifted  author,  while  the  publishers  have  suc- 
ceeded in  bringing  the  externals  into  a  most  felicitous 
harmony  with  the  inspiration  that  dwells  within. 
Take  it  all  in  all,  it  is  a  book  we  have  often  dreamed 
of,  but  dreamed  not  that  it  would  ever  meet  our 
waking  eye  as  a  tangible  reality. — Nashville  Journal 
of  Medicine. 

We  deem  it  fortunate  that  the  splendid  work  of 
Dr.  La  Roche  should  have  been  issued  from  the  press 
at  this  particular  time.  The  want  of  a  reliable  di- 
gest of  all  that  is  known  in  relation  to  this  frightful 
malady  has  long  been  felt — a  want  very  satisfactorily 
met  in  the  work  before  us.  We  deem  it  but  faint 
praise  to  say  that  Dr.  La  Roche  has  succeeded  in 
presenting  the  profession  with  an  able  and  complete 
monograph,  one  which  will  find  its  way  into  every 
well  ordered  library. — Va.  Stethoscope. 

BY  THE  SAME  AUTHOR. 

PNEUMONIA ;  its  Supposed  Connection,  Pathological  and  Etiological,  with  Au- 
tumnal Fevers,  including  an  Inquiry  into  the  Existence  and  Morbid  Agency  of  Malaria.  In  one 
handsome  octavo  volume,  extra  cloth,  of  500  pages.    $3  00. 


We  have  not  time  at  present,  engaged  as  we  are, 
by  faff  and  by  night,  in  the  work  of  combating  this 
very  disease,  now  prevailing  in  our  city,  to  do  more 
than  give  this  cursory  notice  of  what  we  consider 
as  undoubtedly  the  most  able  and  erudite  medical 
publication  our  country  has  yet  produced.  But  in 
view  of  the  startling  fact,  that  this,  the  most  malig- 
nant and  unmanageable  disease  of  modern  times, 
has  for  several  years  been  prevailing  in  our  country 
to  a  greater  extent  than  ever  before;  that  it  is  no 
longer  confined  to  either  large  or  small  cities,  but 
penetrates  country  villages,  plantations,  and  farm- 
houses; that  it  is  treated  with  scarcely  better  suc- 
cess now  than  thirty  or  forty  years  ago ;  that  there 
is  vast  mischief  done  by  ignorant  pretenders  to  know- 
ledge in  regard  to  the  disease,  and  in  view  of  the  pro- 
bability that  a  majority  of  southern  physicians  will 
be  called  upon  to  treat  the  disease,  we  trust  that  this 
able  and  comprehensive  treatise  will  be  very  gene- 
rally read  in  the  south. — Memphis  Med.  Recorder. 

This  is  decidedly  *Ae  great  American  medical  work 
of  the  day — a  full,  complete,  and  systematic  treatise, 
unequalled  by  any  other  upon  the  all-important  sub- 
ject of  Yellow  Fever.  The  laborious,  indefatigable, 
and  learned  author  has  devoted  to  it  many  years  of 


MILLER  (HENRY),  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c. ;  includiog  the  Treat- 

ment  of  Chronic  Inflammation  of  the  Cervix  and  Body  of  the  Uterus  considered  as  a  frequeat 
cause  of  Abortion.  With  about  one  hundred  illustrations  on  wood.  In  one  very  handsome  oc- 
tavo volume,  of  over  600  pages.     (Now  Ready.)    $3  75. 

The  reputation  of  Dr.  Miller  as  an  obstetrician  is  too  widely  spread  to  require  the  attention  of 
the  profession  to  be  specially  called  to  a  volume  containing  the  experience  of  his  long  and  extensive 
practice.  The  very  favorable  reception  accorded  to  his  "  Treatise  on  Human  Parturition,"  issued 
some  years  since,  is  an  earnest  that  the  present  work  will  fulfil  the  author's  intention  of  providing 
within  a  moderate  compass  a  complete  and  trustworthy  text-book  for  the  student,  and  book  of  re- 
ference for  the  practitioner.  Based  to  a  certain  extent  upon  the  former  work,  but  enlarged  to  more 
than  double  its  size,  and  almost  wholly  rewritten,  it  presents,  besides  the  matured  experience  of 
the  author,  the  most  recent  views  and  investigations  of  modern  obstetric  writers,  such  as  Dubois, 
Cazeatjx,  Simpson,  Tyler  Smith,  &c,  thus  embodying  the  results  not  only  of  the  American, 
but  also  of  the  Paris,  the  London,  and  the  Edinburgh  obstetric  schools.  The  author's  position  for  so 
many  years  as  a  teacher  of  his  favorite  branch,  has  given  him  a  familiarity  with  the  wants  of  stu- 
dents and  a  facility  of  conveying  instruction,  which  cannot  fail  to  render  the  volume  eminently 
adapted  to  its  purposes. 


We  congratulate  the  author  that  the  task  is  done. 
We  congratulate  him  that  he  has  given  to  the  medi- 
cal public  a  work  which  will  secure  for  him  a  high 
and  permanent  position  among  the  standard  autho- 
rities on  the  principles  and  practice  of  obstetrics. 
Congratulations  are  not  less  due  to  the  medical  pro- 
fession of  this  country,  on  the  acquisition  of  a  trea- 
tise embodying  the  results  of  the  studies,  reflections, 
and  experience  of  Prof.  Miller.  Few  men,  if  any, 
in  this  country,  are  more  competent  than  he  to  write 
on  this  department  of  medicine.  Engaged  for  thirty- 
five  years  in  an  extended  practice  of  obstetrics,  for 
many  years  a  teacher  of  this  branch  of  instruction 
in  one  of  the  largest  of  our  institutions,  a  diligent 
student  as  well  as  a  careful  observer,  an  original  and 
independent  thinker,  wedded  to  no  hobbies,  ever 
ready  to  consider  without  prejudice  new  views,  and 
to  adopt  innovations  if  they  are  really  improvements, 
und  withal  a  clear,  agreeable  writer,  a  practical 
treatise  from  his  pen  could  not  fail  to  possess  great 
value.  Returning  to  Prof.  Miller's  work  we  have 
only  to  add  that  we  hope  most  sincerely  it  will  be  in 
the  hands  of  every  reading  and  thinking  practitioner 
of  this  country. — Buffalo  Med  Journal,  Mar.  1858. 


In  fact,  this  volume  must  take  its  place  among  the 
standard  systematic  treatises  on  obstetrics  ;  a  posi- 
tion to  which  its  merits  justly  entitle  it.  The  style 
is  such  that  the  descriptions  are  clear,  and  each  sub- 
ject is  discussed  and  elucidated  with  due  regard  to 
its  practical  bearings,  which  cannot  fail  to  make  it 
acceptable  and  valuable  to  both  students  and  prac- 
titioners. We  cannot,  however,  close  this  brief 
notice  without  congratulating  the  author  and  the 
profession  on  the  production  of  such  an  excellent 
treatise.  The  author  is  a  western  man  of  whom  we 
feel  proud,  and  we  cannot  but  think  that  his  book 
will  find  many  readers  and  warm  admirers  wherever 
obstetrics  is  taught  and  studied  as  a  science  and  an 
art.— The  Cincinnati  Lancet  and  Observer,  Feb.  1868. 
%  A  most  respectable  and  valuable  addition  to  our 
home  medical  literature,  and  one  reflecting  credit 
alike  on  the  author  and  the  institution  to  which  he 
is  attached.  The  student  will  find  in  this  work  a 
most  useful  guide  to  his  studies;  the  country  prac- 
titioner, rusty  in  his  reading,  can  obtain  from  its 
pages  a  fair  resume  of  the  modern  literature  of  the 
science;  and  we  hope  to  see  this  American  produc- 
tion generally  consulted  by  the  profession.—  Va. 
Med.  Journal,  Feb.  1858. 


AND    SCIENTIFIC    PUBLICATIONS. 


21 


MEIGS  (CHARLES  D.),  M.  D., 

Professor  of  Obstetrics,  &c.  in  the  Jefferson  Medical  College,  Philadelphia. 

OBSTETRICS :   THE   SCIENCE   AND  THE   ART.     Third  edition,  revised 

and  improved.   With  one  hundred  and  twenty-nine  illustrations.  In  one  beautifully  printed  octavo 

volume,  leather,  of  seven  hundred  and  fifty-two  large  pages.     $3  75. 

The  rapid  demand  for  another  edition  of  this  work  is  a  sufficient  expression  of  the  favorable 
verdict  of  the  profession.  In  thus  preparing  it  a  third  time  for  the  press,  the  author  has  endeavored 
to  render  it  in  every  respect  worthy  of  the  favor  which  it  has  received.  To  accomplish  this  he 
has  thoroughly  revised  it  in  every  part.  Some  portions  have  been  rewritten,  others  added,  new 
illustrations  have  been  in  many  instances  substituted  for  such  as  were  not  deemed  satisfactory, 
while,  by  an  alteration  in  the  typographical  arrangement,  the  size  of  the  work  has  not  been  increased, 
and  the  price  remains  unaltered.  In  its  present  improved  form,  it  is,  therefore,  hoped  that  the  work 
will  continue  to  meet  the  wants  of  the  American  profession  as  a  sound,  practical,  and  extended 
System  of  Midwifery. 


Though  the  work  has  received  only  five  pages  of 
enlargement,  its  chapters  throughout  wear  the  im- 
press of  careful  revision.  Expunging  and  rewriting, 
remodelling  its  sentences,  with  occasional  new  ma- 
terial, all  evince  a  lively  desire  that  it  shall  deserve 
to  be  regarded  as  improved  in  manner  as  well  as 
matter.  In  the  matter,  every  stroke  of  the  pen  has 
increased  the  value  of  the  book,  both  in  expungings 
and  additions  — Western  Lancet.  Jan.  1857. 


The  best  American  work  on  Midwifery  that  is 
accessible  to  the  student  and  practitioner — N.  W. 
Med.  and  Surg.  Journal,  Jan.  1857. 

This  is  a  standard  work  by  a  great  American  Ob- 
stetrician. It  is  the  third  and  last  edition,  and,  in 
the  language  of  the  preface,  the  author  has  "brought 
the  subject  up  to  the  latest  dates  of  real  improve- 
ment in  our  art  and  Science." — Nashville  Journ.  of 
Med.  and  Surg.,  May,  1857. 


BY  the  same  author.     (Lately  Issued.) 

WOMAN:  HER  DISEASES  AND  THEIR  REMEDIES.    A  Series  of  Lee- 

tures  to  his  Class.     Third  and  Improved  edition.    In  one  large  and  beautifully  printed  octavo 

volume,  leather.        pp.  672.     $3  60. 

The  gratifying  appreciation  of  his  labors,  as  evinced  by  the  exhaustion  of  two  large  impressions 
of  this  work  within  a  few  years,  has  not  been  lost  upon  the  author,  who  has  endeavored  in  every 
way  to  render  it  worthy  of  the  favor  with  which  it  has  been  received.  The  opportunity  thus 
afforded  for  a  second  revision  has  been  improved,  and  the  work  is  now  presented  as  in  every  way 
superior  to  its  predecessors,  additions  and  alterations  having  been  made  whenever  the  advance  of 
science  has  rendered  them  desirable.  The  typographical  execution  of  the  work  will  also  be  found 
to  have  undergone  a  similar  improvement,  and  the  work  is  now  confidently  presented  as  in  every 
way  worthy  the  position  it  has  acquired  as  the  standard  American  text-book  on  the  Diseases  of 
Females. 

It  contains  a  vast  amount  of  practical  knowledge, 
by  one  who  has  accurately  observed  and  retained 
the  experience  of  many  years,  and  who  tells  the  re- 
sult in  a  free,  familiar,  and  pleasant  manner. — Dub- 
lin Quarterly  Journal. 

There  is  an  off-band  fervor,  a  glow,  and  a  warm- 
heartedness infecting  the  effort  of  Dr.  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  reader  through  from  beginning  to  end.  Be- 
sides, the  book  teems  with  solid  instruction,  and 
it  shows  the  very  highest  evidence  of  ability,  viz., 
the  clearness  with  which  the  information  is  pre- 
sented. We  know  of  no  better  test  of  one's  under- 
standing a  subject  than  the  evidence  of  the  power 
of  lucidly  explaining  it.  The  most  elementary,  as 
well  as  the  obscurest  subjects,  under  the  pencil  of 
Prof.  Meigs,  are  isolated  and  made  to  stand  out  in 

by  the  same  author.     {Lately  Published.) 

QN    THE    NATURE,    SIGNS,    AND    TREATMENT    OF    CHILDBED 

FEVER.    In  a  Series  of  Letters  addressed  to  the  Students  of  his  Class.    In  one  handsome 
octavo  volume,  extra  cloth,  of  365  pages.    $2  50. 


such  bold  relief,  as  to  produce  distinct  impressions 
upon  the  mind  and  memory  of  the  reader.  —  The 
Charleston  Med.  Journal. 

Professor  Meigs  has  enlarged  and  amended  this 
great  work,  for  such  it  unquestionably  is,  having 
passed  the  ordeal  of  criticism  at  home  and  abroad, 
but  been  improved  thereby  ;  for  in  this  new  edition 
the  author  has  introduced  real  improvements,  and 
increased  the  value  and  utility  of  the  book  im- 
measurably. It  presents  so  many  novel,  bright, 
and  sparkling  thoughts ;  such  an  exuberance  of  new 
ideas  on  almost  every  page,  that  we  confess  our- 
selves to  have  become  enamored  with  the  book 
and  its  author  ;  and  cannot  withhold  our  congratu- 
lations from  our  Philadelphia  confreres,  that  such  a 
teacher  is  in  their  service. — N.  Y.  Med.  Gazette. 


The  instructive  and  interesting  author  of  this 
work,  whose  previous  labors  in  the  department  of 
medicine  which  he  so  sedulously  cultivates,  have 
placed  his  countrymen  under  deep  and  abiding  obli- 
gations, again  challenges  their  admiration  in  the 
fresh  and  vigorous,  attractive  and  racy  pages  before 
us.  It  is  a  delectable  book.  *  *  *  This  treatise 
upon  child-bed  fevers  will  have  an  extensive  sale, 
being  destined,  as  it  deserves,  to  find  a  place  in  the 
library  of  every  practitioner  who  scorns  to  lag  in  the 
rear. — Nashville  Journal  of  Medicine  and  Surgery. 

BY   THE   SAME   AUTHOR  J    WITH  COLORED  PLATES. 

A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK 

OF  THE  UTERUS.    With  numerous  plates,  drawn  and  colored  from  nature  in  the  highest 
style  of  art.    In  one  handsome  octavo  volume,  extra  cloth.     $4  50. 


This  book  will  add  more  to  his  fame  than  either 
of  those  which  bear  his  name.  Indeed  we  doubt 
whether  any  material  improvement  will  be  made  on 
the  teachings  of  this  volume  for  a  century  to  come, 
since  it  is  so  eminently  practical,  and  based  on  pro- 
found knowledge  of  the  science  and  consummate 
skill  in  the  art  of  healing,  and  ratified*  by  an  ample 
and  extensive  experience,  such  as  few  men  have  the 
industry  or  good  fortune  to  acquire. — JV.  Y.  Med. 
Gazette. 


MAYNE'S  DISPENSATORY  AND  THERA- 
PEUTICAL REMEMBRANCER.  Comprising 
the  entire  lists  of  Materia  Medica,  with  every 
Practical  Formula  contained  in  the  three  British 
Pharmacopoeias.  Edited,  with  the  addition  of  the 
Formulas  of  the  U.  S.  Pharmacopoeia,  by  R.  E. 
Griffith, M.D.   1 12mo.  vol.  ex.  cl., 300  pp.  75  c. 


MALGAIGNE'S  OPERATIVE  SURGERY,  based 
on  Normal  and  Pathological  Anatomy.  Trans- 
lated from  the  French  by  Frederick  Brittan, 
A.B.,M.D.  With  numerous  illustrations  on  wood. 
In  one  handsome  octavo  volume,  extra  cloth,  of 
nearly  six  hundred  pages.    $2  25. 


•22 


BLANCHARD   &   LEA'S   MEDICAL 


MACLISE   (JOSEPH),    SURGEON. 

SURGICAL  ANATOMY.  Forming  one  volume,  very  large  imperial  quarto. 
With  sixty-eight  large  and  splendid  Plates,  drawn  in  the  best  style  and  beautifully  colored.  Con- 
taining one  hundred  and  ninety  Figures,  many  of  them  the  size  of  life.  Together  with  copious 
and  explanatory  letter-press.  Strongly  and  handsomely  bound  in  extra  cloth,  being  one  of  the 
cheapest  and  best  executed  Surgical  works  as  yet  issued  in  this  country.  $11  00. 
%*  The  size  of  this  work  prevents  its  transmission  through  the  post-office  as  a  whole,  but  those 

who  desire  to  have  copies  forwarded  by  mail,  can  receive  them  in  five  parts,  done  up  in  stout 

wrappers.     Price  $9  00. 


of  keeping  up  his  anatomical  knowledge. — Medical 
Times. 

The  mechanical  execution  cannot  be  excelled. — 
Transylvania  Medical  Journal. 

A  work  which  has  no  parallel  in  point  of  accu- 
racy and  cheapness  in  the  English  language. — iV.  Y. 
Journal  of  Medicine. 

To  all  engaged  in  the  study  or  practice  of  their 
profession,  such  a  work  is  almost  indispensable. — 
Dublin  Quarterly  Medical  Journal. 

No  practitioner  whose  means  will  admit  should 
fail  to  possess  it. — Ranking^s  Abstract. 

Country  practitioners  will  find  these  plates  of  im- 
mense value. — N.  Y.  Medical  Gazette. 

We  are  extremely  gratified  to  announce  to  the 
profession  the  completion  of  this  truly  magnificent 
work,  which,  as  a  whole,  certainly  stands  unri- 
valled, both  for  accuracy  of  drawing,  beauty  of 
coloring,  and  all  the  requisite  explanations  of  the 
subject  in  hand. — The  New  Orleans  Medical  and 
Surgical  Journal. 

This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy that  has  come  under  our  observation.  We 
know  of  no  other  work  that  would  justify  a  stu- 
dent, in  any  degree,  for  neglect  of  actual  dissec- 
tion. In  those  sudden  emergencies  that  so  often 
arise,  and  which  require  the  instantaneous  command 
of  minute  anatomical  knowledge,  a  work  of  this  kind 
keeps  the  details  of  the  dissecting-room  perpetually 
fresh  in  the  memory. — The  Western  Journal  of  Medi- 
cine and  Surgery. 

The  very  low  price  at  which  this  work  is  furnished,  and  the  beauty  of  its  execution, 
require  an  extended  sale  to  compensate  the  publishers  for  the  heavy  expenses  incurred. 

MULLER'S  PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.    Edited, 

with  Additions,  by  R.  Eglesfeld  Griffith,  M.  D.    In  one  large  and  handsome  octavo  volume, 
extra  cloth,  with  550  wood-cuts,  and  two  colored  plates,    pp.  636.    $3  50. 


One  of  the  greatest  artistic  triumphs  of  the  age 
in  Surgical  Anatomy. — British  American  Medical 
Journal. 

Too  much  cannot  be  said  in  its  praise ;  indeed, 
we  have  not  language  to  do  it  justice. — Ohio  Medi- 
cal and  Surgical  Journal. 

The  most  admirable  surgical  atlas  we  have  seen. 
To  the  practitioner  deprived  of  demonstrative  dis- 
sections upon  the  human  subject,  it  is  an  invaluable 
companion. — N.  J.  Medical  Reporter. 

The  most  accurately  engraved  and  beautifully 
colored  plates  we  have  ever  seen  in  an  American 
book — one  of  the  best  and  cheapest  surgical  works 
ever  published. — Buffalo  Medical  Journal. 

It  is  very  rare  that  so  elegantly  printed,  so  well 
illustrated,  and  so  useful  a  work,  is  offered  at  so 
moderate  a  price. — Charleston  Medical  Journal. 

Its  plates  can  boast  a  superiority  which  places 
them  almost  beyond  the  reach  of  competition. — Medi- 
cal Examiner. 

Every  practitioner,  we  think,  should  have  a  work 
of  this  kind  within  reach. — Southern  Medical  and 
Surgical  Journal. 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  given. — Boston 
Medical  and  Surgical  Journal. 

As  a  surgical  anatomist,  Mr.  Maclise  has  proba- 
bly no  superior.— British  and  Foreign  Medico-Chi- 
rurgical  Review. 

Of  great  value  to  the  student  engaged  in  dissect- 
ing, and  to  the  surgeon  at  a  distance  from  the  means 


PRACTICAL    PHARMACY.     Comprising  the  Arrangements,  Apparatus,  and 

Manipulations  of  the  Pharmaceutical  Shop  and  Laboratory.  Edited,  with  extensive  Additions, 
by  Prof.  William  Procter,  of  the  Philadelphia  College  of  Pharmacy.  In  one  handsomely 
printed  octavo  volume,  extra  cloth,  of  570  pages,  with  over  500  engravings  on  wood.    $2  75. 


MACKENZIE   (W.),    M.D., 

Surgeon  Oculist  in  Scotland  in  ordinary  to  Her  Majesty,  &c.  &c. 

A  PRACTICAL   TREATISE  ON  DISEASES   AND  INJURIES  OF   THE 

EYE.  To  which  is  prefixed  an  Anatomical  Introduction  explanatory  of  a  Horizontal  Section  of 
the  Human  Eyeball,  by  Thomas  Wharton  Jones,  F.  R.  S.  From  the  Fourth  Revised  and  En- 
larged London  Edition.  With  Notes  and  Additions  by  Addinell  Hewson,  M.  D.,  Surgeon  to 
Wills  Hospital,  &c.  &c.  In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  with 
plates  and  numerous  wood-cuts.    $5  25. 


The  treatise  of  Dr.  Mackenzie  indisputably  holds 
the  first  place,  and  forms,  in  respect  of  learning  and 
research,  an  Encyclopaedia  unequalled  in  extent  by 
any  other  work  of  the  kind,  either  English  or  foreign. 
— Dixon  on  Diseases  of  the  Eye. 

Few  modern  books  on  any  department  of  medicine 
or  surgery  have  met  with  such  extended  circulation, 
or  have  procured  for  their  authors  a  like  amount  of 
European  celebrity.  The  immense  research  which 
it  displayed,  the  thorough  acquaintance  with  the 
subject,  practically  as  well  as  theoretically,  and  the 
able  manner  in  which  the  author's  stores  of  learning 
and  experience  were  rendered  available  for  general 
use,  at  once  procured  for  the  first  edition,  as  well  on 
the  continent  as  in  this  country,  that  high  position 
as  a  standard  work  which  each  successive  edition 
has  more  firmly  established,  in  spite  of  the  attrac- 
tions of  several  rivals  of  no  mean  ability.    We  con- 


sider it  the  duty  of  every  one  who  has  the  love  of  his 
profession  and  the  welfare  of  his  patient  at  heart,  to 
make  himself  familiar  with  this  the  most  complete 
work  in  the  English  language  upon  the  diseases  of 
the  eye. — Med.  Times  and  Gazette. 

The  fourth  edition  of  this  standard  work  will  no 
doubt  be  as  fully  appreciated  as  the  three  former  edi- 
tions. It  is  unnecessary  to  say  a  word  in  its  praise, 
for  the  verdict  has  already  been  passed  upon  it  by 
the  most  competent  judges,  and  "  Mackenzie  on  the 
Eye"  has  justly  obtained  a  reputation  which  it  is 
no  figure  of  speech  to  call  world-wide. — British  and 
Foreign  Medico- Chirurgical  Review. 

This  new  edition  of  Dr.  Mackenzie's  celebrated 
treatise  on  diseases  of  the  eye,  is  truly  a  miracle  of 
industry  and  learning.  We  need  scarcely  say  that 
he  has  entirely  exhausted  the  subject  of  his  specialty. 
— Dublin  Quarterly  Journal. 


AND    SCIENTIFIC    PUBLICATIONS. 


23 


MILLER  (JAMES),   F.  R.  S.  E.f 

Professor  of  Surgery  in  the  University  of  Edinburgh,  &c. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and  revised 

Edinburgh  edition.    In  one  large  and  very  beautiful  volume,  leather,  of  700  pages,  with  two 

hundred  and  forty  exquisite  illustrations  on  wood.     {Just  Issued,  1856.)        $3  75. 

The  extended  reputation  enjoyed  by  this  work  will  be  fully  maintained  by  the  present  edition. 
Thoroughly  revised  by  the  author,  it  will  be  found  a  clear  and  compendious  exposition  of  surgical 
science  in  its  most  advanced  condition. 

In  connection  with  the  recently  issued  third  edition  of  the  author's  "Practice  of  Surgery,"  it 
forms  a  very  complete  system  of  Surgery  in  all  its  branches. 


The  work  of  Mr.  Miller  is  too  well  and  too  favor- 
ably known  among  us,  as  one  of  our  best  text-books, 
to  render  any  further  notice  of  it  necessary  than  the 
announcement  of  a  new  edition,  the  fourth  in  our 
country,  a  proof  of  its  extensive  circulation  among 
ns.  As  a  concise  and  reliable  exposition  of  the  sci- 
ence of  modern  surgery,  it  stands  deservedly  high — 
we  know  not  its  superior. — Boston  Med.  and  Surg. 
Journal. 

It  presents  the  most  satisfactory  exposition  of  the 
modern  doctrines  of  the  principles  of  surgery  to  be 
found  in  any  volume  in  any  language. — N.  Y.  Journal 
of  Medicine. 

The  work  takes  rank  with  Watson's  Practice  of 
Physic ;  it  certainly  does  not  fall  behind  that  great 
work  in  soundness  of  principle  or  depth  of  reason- 
ing and  research.    No  physician  who  values  his  re- 

BY  THE  SAME  AUTHOR.      (Now  Ready.) 

THE   PRACTICE   OF   SURGERY.      Fourth  American  from  the  last  Edin- 

burgh  edition.    Revised  by  the  American  editor.    Illustrated  by  three  hundred  and  sixty-four 
engravings  on  wood.    In  one  large  octavo  volume,  leather,  of  nearly  700  pages.     $3  75. 


putation,  or  seeks  the  interests  of  his  clients,  can 
acquit  himself  before  his  God  and  the  world  without 
making  himself  familiar  with  the  sound  and  philo- 
sophical views  developed  in  the  foregoing  book. — 
New  Orleans  Med.  and  Surg.  Journal. 

Without  doubt  the  ablest  exposition  of  the  prin- 
ciples of  that  branch  of  the  healing  art  in  any  lan- 
guage. This  opinion,  deliberately  formed  after  a 
careful  study  of  the  first  edition,  we  have  had  no 
cause  to  change  on  examining  the  second.  This 
edition  has  undergone  thorough  revision  by  the  au- 
thor; many  expressions  have  been  modified,  and  a 
mass  of  new  matter  introduced.  The  book  is  got  up 
in  the  finest  style,  and  is  an  evidence  of  the  progress 
of  typography  in  our  country. — Charleston  Medical 
Journal  and  Review. 


No  encomium  of  ours  could  add  to  the  popularity 
of  Miller's  Surgery.  Its  reputation  in  this  country 
is  unsurpassed  by  that  of  any  other  work,  and,  when 
taken  in  connection  with  the  author's  Principles  of 
Surgery,  constitutes  a  whole,  without  reference  to 
which  no  conscientious  surgeon  would  be  willing 
to  practice  his  art.  The  additions,  by  Dr.  Sargent, 
have  materially  enhanced  the  value  of  the  work.— 
Southern  Medical  and  Surgical  Journal. 

It  is  seldom\that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
"  Principles"  arid  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merited  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  well-informed  man,  who  knows 
exactly  what  he  is  talking  about  and  exactly  how  to 
talk  it.— Kentucky  Medical  Recorder. 

By  the  almost  unanimous  voice  of  the  profession, 


his  works,  both  on  the  principles  and  practice  of 
surgery  have  been  assigned  the  highest  rank.  If  we 
were  limited  to  but  one  work  on  surgery,  that  one 
should  be  Miller's,  as  we  regard  it  as  superior  to  all 
others. — St.  Louis  Med.  and  Surg.  Journal. 

The  author,  distinguished  alike  as  a  practitioner 
and  writer,  has  in  this  and  his  "  Principles,"  pre- 
sented to  the  profession  one  of  the  most  complete  and 
reliable  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, concise,  and  lucid.  Few  have  the  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  the  attention ;  indeed, 
he  appears  to  make  the  very  process  of  condensation 
a  means  of  eliminating  attractions.  Whether  as  a 
text-book  for  students  or  a  book  of  reference  for 
practitioners,  it  cannot  be  too  strongly  recommend- 
ed.— Southern  Journal  of  Med.  and  Phys.  Sciences. 


MONTGOMERY  (W.  F.),    M.  D.,  M.  R.  I.  A.,  &c, 

Professor  of  Midwifery  in  the  King  and  Queen's  College  of  Physicians  in  Ireland,  &c. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

With  some  other  Papers  on  Subjects  connected  with  Midwifery.    From  the  second  and  enlarged 
English  edition.    With  two  exquisite  colored  plates,  and  numerous  wood-cuts.    In  one  very 
handsome  octavo  volume,  extra  cloth,  of  nearly  600  pages.     {Just  Issued,  1857.)    $3  75. 
The  present  edition  of  this  classical  volume  is  fairly  entitled  to  be  regarded  as  anew  work,  every 
sentence  having  been  carefully  rewritten,  and  the  whole  increased  to  more  than  double  the  original 
size.     The  title  of  the  work  scarcely  does  justice  to  the  extent  and  importance  of  the  topics 
brought  under  consideration,  embracing,  with  the  exception  of  the  operative  procedures  of  mid- 
wifery, almost  everything  connected  with  obstetries,  either  directly  or  incidentally ;  and  there  are 
few  physicians  who  will  not  find  in  its  pages  much  that  will  prove  of  great  interest  and  value  in 
their  daily  practice.     The  special  Essays  on  the  Period  of  Human  Gestation,  the  Signs  of  Delivery, 
and  the  Spontaneous  Amputation  and  other  Lesions  of  the  Foetus  in  Utero  present  topics  of  the 
highest  interest  fully  treated  and  beautifully  illustrated. 

In  every  point  of  mechanical  execution  the  work  will  be  found  one  of  the  handsomest  yet  issued 
from  the  American  press. 


A  book  unusually  rich  in  practical  suggestions. — 
Am.  Journal  Med.  Sciences,  Jan.  1857. 

These  several  subjects  so  interesting  in  them- 
selves, and  so  important,  every  one  of  them,  to  the 
most  delicate  and  precious  of  social  relations,  con- 
trolling often  the  honor  and  domestic  peace  of  a 
family,  the  legitimacy  of  offspring,  or  the  life  of  its 
parent,  are  all  treated  with  an  elegance  of  diction, 
fulness  of  illustrations,  acutenessand  justice  of  rea- 
soning, unparalleled  in  obstetrics,  and  unsurpassed  in 
medicine.  The  reader's  interest  can  never  flag,  so 
fresh,  and  vigorous,  and  classical  is  our  author's 
style;  and  one  forgets,  in  the  renewed  charm  of 
every  page,  that  it,  and  every  line,  and  every  word 


has  been  weighed  and  reweighed  through  years  of 
preparation ;  that  this  is  of  all  others  the  book  of 
Obstetric  Law,  on  each  of  its  several  topics  ;  on  all 
points  connected  with  pregnancy,  to  be  everywhere 
received  as  a  manual  of  special  jurisprudence?  at 
once  announcing  fact,  affording  argument,  establish- 
ing precedent,  and  governing  alike  the  juryman,  ad- 
vocate, and  judge.  It  is  not  merely  in  its  legal  re- 
lations that  we  find  this  work  so  interesting.  Hardly 
a  page  but  that  has  its  hints  or  facts  important  to 
the  general  practitioner ;  and  not  a  chapter  without 
especial  matter  for  the  anatomist,  physiologist,  or 
pathologist.  —  N.  A.  Med.-Chir.  Review,  March, 
1857. 


24 


BLANCHARD    &   LEA'S   MEDICAL 


NEILL  (JOHN),   M.  D., 

Surgeon  to  the  Pennsylvania  Hospital,  &c;  and 

RANiniS    ftlJRNIPY    SMITH.    MP 


FRANCIS  GORNEY  SMITH,   M.D.. 

Professor  of  Institutes  of  Medicine  in  the  Pennsylvania  Medical  College. 

AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS  BRANCHES 

OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.    A  new  edition,  revised 
and  improved.    In  one  very  large  and  handsomely  printed  royal  12mo.  volume,  of  about  one 
thousand  pages,  with  374  wood-cuts.     Strongly  bound  in  leather,  with  raised  bands.     $3  00. 
The  very  flattering  reception  which  has  been  accorded  to  this  work,  and  the  high  estimate  placed 
upon  it  by  the  profession,  as  evinced  by  the  constant  and  increasing  demand  which  has  rapidly  ex- 
hausted two  large  editions,  have  stimulated  the  authors  to  render  the  volume  in  its  present  revision 
more  worthy  of  the  success  which  has  attended  it.    It  has  accordingly  been  thoroughly  examined, 
and  such  errors  as  had  on  former  occasions  escaped  observation  have  been  corrected,  and  whatever 
additions  were  necessary  to  maintain  it  on  a  level  with  the  advance  of  science  have  been  introduced. 
The  extended  series  of  illustrations  has  been  still  further  increased  and  much  improved,  while,  by 
a  slight  enlargement  of  the  page,  these  various  additions  have  been' incorporated  without  increasing 
the  bulk  of  the  volume. 

The  work  is,  therefore,  again  presented  as  eminently  worthy  of  the  favor  with  which  it  has  hitherto 
been  received.  As  a  book  for  daily  reference  by  the  student  requiring  a  guide  to  his  more  elaborate 
text-books,  as  a  manual  for  preceptors  desiring  to  stimulate  their  students  by  frequent  and  accurate 
examination,  or  as  a  source  from  which  the  practitioners  of  older  date  may  easily  and  cheaply  acquire 
a  knowledge  of  the  changes  and  improvement  in  professional  science,  its  reputation  is  permanently 
established. 


The  best  work  of  the  kind  with  which  we  are 
acquainted. — Med.  Examiner. 

Having  made  free  use  of  this  volume  in  our  ex- 
aminations of  pupils,  we  can  speak  from  experi- 
ence in  recommending  it  as 'an  admirable  compend 
for  students,  and  as  especially  useful  to  preceptors 
who  examine  their  pupils.  It  will  save  the  teacher 
much  labor  by  enabling  him  readily  to  recall  all  of 
the  points  upon  which  his  pupils  should  be  ex- 
amined. A  work  of  this  Bort  should  be  in  the  hands 
of  every  one  who  takes  pupils  into  his  office  with  a 
view  of  examining  them;  and  this  is  unquestionably 
thebestof  its  class. — Transylvania  Med.  Journal. 

In  the  rapid  course  of  lectures,  where  work  for 


the  students  is  heavy,  and  review  necessary  for  an 
examination,  a  compend  is  not  only  valuable,  but 
it  is  almost  a  sine  qua  non.  The  one  before  us  is, 
in  most  of  th.e  divisions,  the  most  unexceptionable 
of  all  books  of  the  kind  that  we  know  of.  Th* 
newest  and  soundest  doctrines  and  the  latest  im- 
provements and  discoveries  are  explicitly,  though 
concisely,  laid  before  the  student.  There  is  a  class 
to  whom  we  very  sincerely  commend  this  cheap  book 
as  worth  its  weight  in  silver — that  class  is  the  gradu- 
ates in  medicine  of  more  than  ten  years'  standing, 
who  have  not  studied  medicine  since.  They  will 
perhaps  find  out  from  it  that  the  science  is  not  exactly 
now  what  it  was  when  they  left  it  off. — The  Stetho- 
scope 


NEILL   (JOHN),    M.  D., 

Professor  of  Surgery  in  the  Pennsylvania  Medical  College,  &c. 

OUTLINES  OF  THE  VEINS  AND  LYMPHATICS.     With  handsome  colored 

plates.     1  vol.,  cloth.  $1  25. 

OUTLINES  OF  THE  NERVES.     With  handsome  plates.     1  vol.,  cloth.  $1  25. 


NELIGAN  (J.    MOORE),  M.  D.,  M.  R.  I. A.,  &.C. 

(A  splendid  work.     Just  Issued.) 

ATLAS  OF  CUTANEOUS  DISEASES.     In  one  beautiful  quarto  volume,  extra 

cloth,  with  splendid  colored  plates,  presenting  nearly  one  hundred  elaborate  representations  of 

disease.    $4  50. 

This  beautiful  volume  is  intended  as  a  complete  and  accurate  representation  of  all  the  varieties 
of  Diseases  of  the  Skin.  While  it  can  be  consulted  in  conjunction  with  any  work  on  Practice,  it  has 
especial  reference  to  the  author's  "  Treatise  on  Diseases  of  the  Skin,"  so  favorably  received  by  the 
profession  some  years  since.  The  publishers  feel  justified  in  saying  that  few  more  beautifully  exe- 
cuted plates  have  ever  been  presented  to  the  profession  of  this  country. 


A  compend  which  will  very  much  aid  the  practi- 
tioner in  this  difficult  branch  of  diagnosis.  Taken 
with  the  beautiful  plates  of  the  Atlas,  which  are 
remarkable  for  their  accuracy  and  beauty  of.  color- 
ing, it  constitutes  a  very  valuable  addition  to  the 
library  of  a  practical  man.—  Buffalo  Med.  Journal, 
Sept. 1856. 

Nothing  is  often  more  difficult  than  the  diagnosis 
of  disease  of  the  skin ;  and  hitherto,  the  only  works 
containing  illustrations  have  been  at  rather  incon- 
venient prices — prices,  indeed,  that  prevented  gene- 
ral use.  The  work  before  us  will  supply  a  want 
Ion?  felt,  and  minister  to  a  more  perfect  acquaintance 
with  the  nature  and  treatment  of  a  very  frequent 
and  troublesome  form  of  disease. —  Ohio  Med.  and 
Surg.  Journal,  July,  1856. 

Neligan's  AtlaB  of  Cutaneous  Diseases  supplies  a 


long  existent  desideratum  much  felt  by  the  largest 
class  of  our  profession.  It  presents,  in  quarto  size, 
16  plates,  each  containing  from  3  to  6  figures,  and 
forming  in  all  a  total  of  90  distinct  representations 
of  the  different  species  of  skin  affections,  grouped 
together  in  genera  or  families.  The  illustrations 
have  been  taken  from  nature,  and  have  been  copied 
with  such  fidelity  that  they  present  a  striking  picture 
of  life;  in  which  the  reduced  scale  aptly  serves  to 
give,  at  a  coup  d'czil,  the  remarkable  peculiarities 
of  each  individual  variety.  And  while  thus  the  dis 
ease  is  rendered  more  definable,  there  is  yet  no  loss 
of  proportion  incurred  by  the  necessary  concentra- 
tion. Each  figure  is  highly  colored,  and  so  truthful 
has  the  artist  been  that  the  most  fastid  ous  observer 
could  not  justly  take  exception  to  the  correctness  of 
the  execution  of  the  pictures  under  his  scrutiny. — 
Montreal  Med.  Chronicle. 


BY  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE   ON   DISEASES   OF  THE    SKIN.     Second 

American  edition.    In  one  neat  royal  12mo.  volume,  extra  cloth,  of  334  pages.    $1  00. 
The  two  volumes  will  be  sent  by  mail  on  receipt  of  Five  Dollars. 


OWEN  ON  THE  DIFFERENT  FORMS  OF 
THE  SKELETON,  AND  OF  THE  TEETH. 


One  vol.  royal  12mo.,  extra  cloth,  with  numerous 
illustrations.    (Just  Issued.)    $1  25. 


AN 


ENTIFIO   PUBLICATIONS, 


25 


(Now  Complete.) 

PEREIRA  (JONATHAN),  M.  D.f  F.  R.  S.,  AND  L.  S. 

THE    ELEMENTS    OF   MATERIA    MEDICA    AND    THERAPEUTICS. 

Third  American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medicinal  Substances  in  use  in  the  civilized  world,  and  forming  an  Encyclopaedia  of  Materia 
Medica.  Edited,  with  Additions,  bv  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  of  2100  pages, 
on  small  type,  with  about  500  illustrations  on  stone  and  wood,  strongly  bound  in  leather,  with 
raised  bands.     $9  00. 

Gentlemen  who  have  the  first  volume  are  recommended  to  complete  their  copies  without  delay. 
The  first  volume  will  no  longer  be  sold  separate.    Price  of  Vol.  II.  $5  00. 


The  third  edition  of  his  "  Elements  of  Materia 
Medica,  although  completed  under  the  supervision  of 
others,  is  by  far  the  most  elaborate  treatise  in  the 
English  language,  and  will,  while  medical  literature 
is  cherished,  continue  a  monument  alike  honorable 
to  his  genius,  as  to  his  learning  and  industry.— 
American  Journal  of  Pharmacy. 

Our  own  opinion  of  its  merits  is  that  of  its  editors, 
and  also  that  of  the  whole  profession,  both  of  this 
and  foreign  countries— namely,  "  that  in  copious- 
ness of  details,  in  extent,  variety,  and  accuracy  of 
information,  and  in  lucid  explanation  of  difficult 
and  recondite  subjects,  it  surpasses  all  other  works 
on  Materia  Medica  hitherto  published."  We  can- 
not close  this  notice  without  alluding  to  the  special 
additions  of  the  American  editor,  which  pertain  to 
the  prominent  vegetable  productions  of  this  country, 


and  to  the  directions  of  the  United  States  Pharma- 
copoeia, in  connection  with  all  fhe  articles  contained 
in  the  volume  which  are  referred  to  by  it.  The  il- 
lustrations have  been  increased,  and  this  edition  by 
Dr.  Carson  cannot  well  be  regarded  in  any  other 
light  than  that  of  a  treasure  which  should  be  found 
in  the  library  of  every  physician. — New  York  Journ- 
al of  Medical  and  Collateral  Science. 

The  work,  in  its  present  shape,  forms  the  most 
comprehensive  and  complete  treatise  on  materia 
medica  extant  in  the  English  language.  The  ac- 
counts of  the  physiological  and  therapeutic  effects 
of  remedies  are  given  with  great  clearness  and  ac- 
curacy, and  in  a  manner  calculated  to  interest  as 
well  as  instruct  the  reader. — Edinburgh  Medical 
and  Surgical  Journal. 


PEASLEE  (E.  R.),   M.  D., 

Professor  of  Physiology  and  General  Pathology  in  the  New  York  Medical  College. 

HUMAN  HISTOLOGY,  in  its  relations  to  Anatomy,  Physiology,  and  Pathology; 
for  the  use  of  Medical  Students.  With  four  hundred  and  thirty- four  illustrations.  In  one  hand- 
some octavo  volume,  of  over  600  pages.     (Now  Ready.)    $3  75. 

The  rapid  advances  made  of  late  years  in  our  knowledge  of  the  structure  and  functions  of  the 
elements  which  constitute  the  human  body,  have  rendered  the  subject  of  Histology  of  the  highest 
importance  to  all  who  regard  medicine  as  a  science.  At  the  same  time,  the  vast  body  of  facts 
covered  by  Physiology  has  caused  our  text-books  on  that  subject  to  be  necessarily  restricted  in 
their  treatment  of  the  portions  devoted  to  Histology.  A  want  has,  therefore,  arisen  of  a  work  de- 
voted especially  to  the  minute  anatomy  of  the  body,  giving  a  complete  and  detailed  account  of  the 
structure  of  the  various  tissues,  as  well  as  the  solids  and  fluids,  in  all  the  different  organs— their 
functions  in  health,  and  their  changes  in  disease.  In  undertaking  this  task,  the  author  has  endea- 
vored to  present  his  extensive  subject  in  the  manner  most  likely  to  interest  and  benefit  the  physician, 
confident  that  in  these  details  will  be  found  the  basis  of  true  medical  science.  The  very  large 
number  of  illustrations  introduced  throughout,  serves  amply  to  elucidate  the  text,  while  the  typo- 
graphy of  the  Volume  will  in  every  respect  be  found  of  the  handsomest  description. 
It  embraces  a  library  upon  the  topics  discussed 


within  itself,  and  is  just  what  the  teacher  and  learner 
need.  Another  advantage,  by  no  means  to  be  over- 
looked, everything  of  real  value  in  the  wide  rarge 
which  it  embraces,  is  with  great  skill  compressed 
into  an  octavo  volume  of  but  little  more  than  six 
hundred  pages.  We  have  not  only  the  whole  sub- 
ject of  Histology,  interesting  in  itself,  ably  and  fully 
discussed,  but  what  is  of  infinitely  greater  interest 
to  the  student,  because  of  greater  practical  value, 
are  its  relations  to  Anatomy,  Physiology,  and  Pa- 
thology, which  are  here  fully  and  satisfactorily  set 
forth.  These  great  supporting  branches  of  practical 
medicine  are  thus  linked  together,  and  while  estab- 
lishing and  illustrating  each  other,  are  interwoven 


into  a  harmonious  whole.  We  commend  the  work 
to  students  and  physicians  generally.  —  Nashville 
Journ.  of  Med.  and  Surgery,  Dec.  1857. 

It  far  surpasses  our  expectation.  We  never  con- 
ceived the  possibility  of  compressing  so  much  valu- 
able information  into  so  compact  a  form.  We  will 
not  consume  space  with  commendations.  We  re- 
ceive this  contribution  to  physiological  science, 
"  JNot  with  vain  thanks,  but  with  acceptance  boun- 
teous." We  have  already  paid  it  the  practical 
compliment  of  making  abundant  use  of  it  in  the 
preparation  of  our  lectures,  and  also  of  recommend- 
ing its  further  perusal  most  cordially  to  our  alumni ; 
a  recommendation  which  we  now  extend  to  our 
readers. — Memphis  Med.  Recorder,  Jan.  1$53. 


PIRRIE  (WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.    Edited  by  John 

Neill  M  D    Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the  Pennsylvania 

Hospital,  &c.   In  one  very  handsome  octavo  volume,  leather,  of  780  pages,  with  316  illustrations. 

$3  75. 

We  know  of  no  other  surgical  work  of  a  reason- 
able size,  wherein  there  is  so  much  theory  and  prac- 
tice, or  where  subjects  are  more  soundly  or  clearly 
taught. — The  Stethoscope. 


There  is  scarcely  a  disease  of  the  bones  or  soft 
j>arts,  fracture,  or  dislocation,  that  is  not  illustrated 
by  accurate  wood-engravings.  Then,  again,  every 
instrument  employed  by  the  surgeon  is  thus  repre- 
sented. These  engravings  are  not  only  correct,  but 
really  beautiful,  showing  the  astonishing  degree  of 
perfection  to  which  the  art  of  wood-engraving  has 


arrived.  Prof.  Pirrie,  in  the  work  before  us,  has 
elaborately  discussed  the  principles  of  surgery,  and 
a  safe  and  effectual  practice  predicated  upon  them. 
Perhaps  no  work  upon  this  subject  heretofore  issued 
is  so  full  upon  the  science  of  the  art  of  surgery. — 
Nashville  Journal  of  Medicine  and  Surgery. 

One  of  the  best  treatises  on  surgery  in  the  English 
language. — Canada  Med.  Journal. 

Our  impression  is,  that,  as  a  manual  for  students, 
Pirrie's  is  the  best  work  extant. — Western  Med.  and 
Surg.  Journal. 


PARKER   (LANGSTON), 

Surgeon  to  the  Queen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OF  SYPHILITIC  DISEASES,  BOTH  PRI- 

MARY  AND  SECONDARY;  comprising  the  Treatment  of  Constitutional  and  Confirmed  Syphi- 
lis bv  a  safe  and  successful  method.  With  numerous  Cases,  Formulae,  and  Clinical  Observa- 
tions. From  the  Third  and  entirely  rewritten  London  edition.  In  one  neat  octavo  volume, 
extra  cloth,  of  316  pages.    $1  75. 


20 


BLANCHARD    &    LEA'S   MEDICAL 


PARRISH    (EDWARD), 

Lecturer  on  Practical  Pharmacy  and  Materia  Medica  in  the  Pennsylvania  Academy  of  Medicine,  &c. 

AN  INTRODUCTION  TO  PRACTICAL  PHARMACY.     Designed  as  a  Text- 

Book  for  the  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  For- 
mulae and  Prescriptions.  In  one  handsome  octavo  volume,  extra  cloth,  of  550  pages,  with  243 
Illustrations.   $2  75. 


A  careful  examination  of  this  work  enables  us  to 
speak  of  it  in  the  highest  terms,  as  being  the  best 
treatise  on  practical  pharmacy  ■with  which  we  are 
acquainted,  and  an  invaluable  vade-mecum,  not  only 
to  the  apothecary  and  to  those  practitioners  who  are 
accustomed  to  prepare  their  own  medicines,  but  to 
every  medical  man  and  medical  student.  Through- 
out the  work  are  interspersed  valuable  tables,  useful 
formula?,  and  practical  hints,  and  the  whole  is  illus- 
trated by  a  large  number  of  excellent  wood-engrav- 
ings.— Boston  Med.  and  Surg.  Journal. 

This  is  altogether  one  of  the  most  useful  books  we 
have  seen.  It  is  just  what  we  have  long  felt  to  be 
needed  by  apothecaries,  students,  and  practitioners 
of  medicine,  most  of  whom  in  this  country  have  to 
put  up  their  own  prescriptions.  It  bears,  upon  every 
page,  the  impress  of  practical  knowledge,  conveyed 
in  a  plain  common  sense  manner,  and  adapted  to  the 
comprehension  of  all  who  may  read  it.  No  detail 
has  been  omitted,  however  trivial  it  may  seem,  al- 
though really  important  to  the  dispenser  of  medicine. 
— Southern  Med.  and  Surg.  Journal. 

To  both  the  country  practitioner  and  the  city  apo- 
thecary this  work  of  Mr.  Parrish  is  a  godsend.  A 
careful  study  of  its  contents  will  give  the  young 
graduate  a  familiarity  with  the  value  and  mode  of 
administering  his  prescriptions,  which  will  be  of  as 
much  use  to  his  patient  as  to  himself. — Va.  Med. 
Journal. 

Mr.  Parrish  has  rendered  a  very  acceptable  service 
to  the  practitioner  and  student,  by  furnishing  this 
book,  which  contains  the  leading  facts  and  principles 
of  the  science  of  Pharmacy,  conveniently  arranged 
for  study,  and  with  special  reference  to  those  features 
of  the  subject  which  possess  an  especial  practical  in- 
terest to  the  physician.  It  furnishes  the  student,  at 
the  commencement  of  his  studies,  with  that  infor- 
mation which  is  of  the  greatest  importance  in  ini- 
tiating him  into  the  domain  of  Chemistry  and  Materia 


Medica;  it  familiarizes  him  with  the  compounding 
of  drugs,  and  supplies  those  minutiae  which  but  few 
practitioners  can  impart.  The  junior  practitioner 
will,  also,  find  this  volume  replete  with  instruction. 
— Charleston  Med.  Journal  and  Review,  Mar.  1856. 

There  is  no  useful  information  in  the  details  of  the 
apothecary's  or  country  physician's  office  conducted 
according  to  science  that  is  omitted.  The  young 
physician  will  find  it  an  encyclopedia  of  indispensa- 
ble medical  knowledge,  from  the  purchase  of  a  spa- 
tula to  the  compounding  of  the  most  learned  pre- 
scriptions. The  work  is  by  theablest  pharmaceutist 
in  the  United  States,  and  must  meet  with  an  im- 
mense sale. — Nashville  Journal  of  Medicine,  April, 
1856. 

We  are  glad  to  receive  this  excellent  work.  It 
will  supply  a  want  long  felt  by  the  profession,  and 
especially  by  the  student  of  Pharmacy.  A  large 
majority  of  physicians  are  obliged  to  compound 
their  own  rrtedicines,  and  to  them  a  work  of  this 
kind  is  indispensable. — N.  0.  Medical  and  Surgical 
Journal . 

We  cannot  say  but  that  this  volume  is  one  of  the 
most  welcome  and  appropriate  which  has  for  a  long 
time  been  issued  from  the  press.  It  is  a  work  which 
we  doubt  not  will  at  once  secure  an  extensive  cir- 
culation, as  it  is  designed  not  only  for  the  druggist 
and  pharmaceutist,  but  also  for  the  great  body  of 
practitioners  throughout  the  country,  who  not  only 
have  to  prescribe  medicines,  but  in  the  majority  of 
instances  have  to  rely  upon  their  own  resources — 
whatever  these  may  be — not  only  to  compound,  but 
also  to  manufacture  the  remedies  they  are  called 
upon  to  administer.  The  author  has  not  mistaken 
the  idea  in  writing  this  volume,  as  it  is  alike  useful 
and  invaluable  to  those  engaged  in  the  active  pur- 
suits of  the  profession,  and  to  those  preparing  to  en- 
ter upon  the  field  of  professional  labors. — American 
Lancet,  March  24,  1856. 


R1CORD  (P.),   M.  D., 
A  TREATISE  ON  THE  VENEREAL  DISEASE.     By  John  Hunter,  F.  R.  S 

With  copious  Additions,  by  Ph.  Ricord,  M.  D.     Edited,  with  Notes,  by  Freeman  J.  Bumstead 
M.  D.    In  one  handsome  octavo  volume,  extra  cloth,  of  520  pages,  with  plates.     $3  25. 
Every  one  will  recognize  the  attractiveness  and 

value  which  this  work  derives  from  thus  presenting 

the  opinions  of  these  two  masters  side  by  side.    But, 

it  must  be  admitted,  what  has  made  the  fortune  of 

the  book,  is  the  fact  that  it  contains  the  "  most  com- 
plete embodiment  of  the  veritable  doctrines  of  the 

Hopital  du  Midi,"  which  has  ever  been  made  public. 

The  doctrinal  ideas  of  M.  Ricord,  ideas  which,  if  not 

universally  adopted,  are  incontestably  dominant,  have 

heretofore  only  been  interpreted  by  more  or  less  skilful 


ILLUSTRATIONS  OF  SYPHILITIC  DISEASE. 
Translated  by  Thomas  F.  Betton,  M.D.  With 
fifty  large  quarto  colored  plates.  In  one  large 
quarto  volume,  extra  cloth.    $15  00. 


secretaries,  sometimes  accredited  and  sometimes  not. 
In  the  notes  to  Hunter,  the  master  substitutes  him- 
self for  his  interpreters,  and  gives  his  original  thoughts 
to  the  world  in  a  lucid  and  perfectly  intelligible  man- 
ner. In  conclusion  we  can  say  that  this  is  incon- 
testably the  best  treatise  on  syphilis  with  which  we 
are  acquainted,  and,  as  we  do  not  often  employ  the 
phrase,  we  may  be  excused  for  expressing  the  hope 
that  it  may  find  a  place  in  the  library  of  every  phy- 
sician.—  Virginia  Med.  and  Surg.  Journal. 

BY   THE  SAME   AUTHOR. 

LETTERS  ON  SYPHILIS,  addressed  to  the  Chiel 
Editor  of  the  Union  Medicale.  Translated  by  W. 
P.  Lattimore,  M.D.  In  one  neat  octavo  vol- 
ume, of  270  pages,  extra  cloth.    $2  00. 


RIGBY   (EDWARD),    M.  D., 

Senior  Physician  to  the  General  Lying-in  Hospital,  &c. 

A    SYSTEM    OF    MIDWIFERY.     With  Notes  and  Additional  Illustrations. 
Second  American  Edition.    One  volume  octavo,  extra  cloth,  422  pages.    $2  50. 

by  the  same  author.     (Note  Ready,  1857.) 

ON  THE   CONSTITUTIONAL  TREATMENT  OF  FEMALE  DISEASES. 

In  one  neat  royal  12mo.  volume,  extra  cloth,  of  about  250  pages.    $1  00. 

The  aim  of  the  author  has  been  throughout  to  present  sound  practical  views  of  the  important 
subjects  under  consideration  ;  and  without  entering  into  theoretical  disputations  and  disquisitions  to 
embody  the  results  of  his  long  and  extended  experience  in  such  a  condensed  form  as  would  be 
easily  accessible  to  the  practitioner. 


ROYLE'S   MATERIA   MEDICA   AND   THERAPEUTICS;   including  the 

Preparations  of  the  Pharmacopoeias  of  London,  Edinburgh,  Dublin,  and  of  the  United  States. 
With  many  new  medicines.  Edited  by  Joseph  Carson,  M.  D.  With  ninety-eight  illustrations. 
In  one  large  octavo  volume,  extra  cloth,  of  about  700  pages.    $3  00. 


AND    SCIENTIFIC    PUBLICATIONS. 


27 


RAMSBOTHAM  (FRANCIS  H.),   M.D. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND 

SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly 
revised  by  the  Author.  With  Additions  by  W.  V.  Keating,  M.  D.  In  one  large  and  handsome 
imperial  octavo  volume,  of  650  pages,  strongly  bound  in  leather,  with  raised  bands;  with  sixty- 
four  beautiful  Plates,  and  numerous  Wood-cuts  in  the  text,  containing  in  all  nearly  two  hundred 
large  and  beautiful  figures.   (Lately  Issued,  1856.)  $5  00. 

In  calling  the  attention  of  the  profession  to  the  new  edition  of  this  standard  work,  the  publishers 
would  remark  that  no  efforts  have  been  spared  to  secure  for  it  a  continuance  and  extension  of  the 
remarkable  favor  with  which  it  has  been  received.  The  last  London  issue,  which  was  considera- 
bly enlarged,  has  received  a  further  revision  from  the  author,  especially  for  this  country.  Its  pas-  . 
sage  through  the  press  here  has  been  supervised  by  Dr.  Keating,  who  has  made  numerous  addi-  / 
tions  with  a  view  of  presenting  more  fully  whatever  was  necessary  to  adapt  it  thoroughly  to 
American  modes  of  practice.  In  its  mechanical  execution,  a  like  superiority  over  former  editions 
will  be  found. 

From  Prof.  Hodge,  of  the  University  of  Pa. 
To  the  American  public,  it  is  most  valuable,  from  its  intrinsic  undoubted  excellence,  and  as  being 
the  best  authorized  exponent  of  British  Midwifery.    Its  circulation  will,  I  trust,  be  extensive  throughout 
our  country. 


The  publishers  have  shown  their  appreciation  of 
the  merits  of  this  work  and  secured  its  success  by 
the  truly  elegant  style  in  which  they  have  brought 
it  out,  excelling  themselves  in  its  production,  espe- 
cially in  its  plates.  It  is  dedicated  to  Prof.  Meigs, 
and  has  the  emphatic  endorsement  of  Prof.  Hodge, 
as  the  best  exponent  of  British  Midwifery.  We 
know  of  no  text-book  which  deserves  in  all  respects 
to  be  more  highly  recommended  to  students,  and  we 
could  wish  to  see'it  in  the  hands  of  every  practitioner, 
for  they  will  find  it  invaluable  for  reference. — Med . 
Gazette.  * 

But  once  in  a  long  time  some  brilliant  genius  rears 
his  head  above  the  horizon  of  science,  and  illumi- 
nates and  purifies  every  department  that  he  investi- 
gates ;  and  his  works  become  types,  by  which  innu- 
merable imitators  model  their  feeble  productions. 
Such  a  genius  we  find  in  the  younger  Ramsbotham, 
and  such  a  type  we  find  in  the  work  now  before  us. 
The  binding,  paper,  type,  the  engravings  and  wood- 
cuts are  all  so  excellent  as  to  make  this  book  one  of 
the  finest  specimens  of  the  art  of  printing  that  have 
given  such  a  world-wide  reputation  to  its  enter- 
prising and  liberal  publishers.  We  welcome  Rams- 
botham's  Principles  and  Practice  of  Obstetric  Medi- 


cine and  Surgery  to  our  library,  and  confidently 
recommend  it  to  our  readers,  with  the  assurance 
that  it  will  not  disappoint  their  most  sanguine  ex- 
pectations.— Western  Lancet. 

It  is  unnecessary  to  say  anything  in  regard  to  the 
utility  of  this  work.  It  is  already  appreciated  in  our 
country  for  the  value  of  the  matter,  the  clearness  of 
its  style,  and  the  fulness  of  its  illustrations.  To  the 
physician's  library  it  is  indispensable,  while  to  the 
student  as  a  text-book,  from  which  to  extract  the 
material  for  laying  the  foundation  of  an  education  on 
obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  Journal. 

We  will  only  add  that  the  student  will  learn  from 
it  all  he  need  to  know,  and  the  practitioner  will  find 
it,  as  a  book  of  reference,  surpassed  by  none  other. — 
Stethoscope. 

The  character  and  merits  of  Dr.  Rarnsbotham's 
work  are  so  well  known  and  thoroughly  established, 
that  comment  is  unnecessary  and  praise  superfluous. 
The  illustrations,  which  are  numerous  and  accurate, 
are  executed  in  the  highest  style  of  art.  We  cannot 
too  highly  recommend  the  work  to  our  readers. — St. 
Louis  Med.  and  Surg.  Journal. 


ROKITANSKY  (CARL),    M.D., 
Curator  of  the  Imperial  Pathological  Museum,  and  Professor  at  the  University  of  Vienna,  &c. 

A    MANUAL   OF  PATHOLOGICAL    ANATOMY.     Four  volumes,   octavo, 

bound  in  two,  extra  cloth,  of  about  1200  pages.     Translated  by  W.  E.  Swaine,  Edward  Sieve- 
king;  C.  H.  Moore,  and  G.  E.  Day.     (Just  Issued.)   $5  50 
To  render  this  large  and  important  work  more  easy  of  reference,  and  at  the  same  time  less  cum- 
brous and  costly,  the  four  volumes  have  been  arranged  in  two,  retaining,  however,  the  separate 
paging,  &c. 

The  publishers  feel  much  pleasure  in  presenting  to  the  profession  of  the  United  States  the  great 
work  of  Prof.  Rokitansky,  which  is  universally  referred  to  as  the  standard  of  authority  by  the  pa- 
thologists of  all  nations.  Under  the  auspices  of  the  Sydenham  Society  of  London,  the  combined 
labor  of  four  translators  has  at  length  overcome  the  almost  insuperable  difficulties  which  have  so 
long  prevented  the  appearance  of  the  work  in  an  English  dress.  To  a  work  so  widely  known, 
eulogy  is  unnecessary,  and  the  publishers  would  merely  state  that  it  is  said  to  contain  the  results 
of  not  less  than  thirty  thousand  post-mortem  examinations  made  by  the  author,  diligently  com- 
pared, generalized,  and  wrought  into  one  complete  and  harmonious  system. 


The  profession  is  too  well  acquainted  with  the  re- 
putation of  Rokitansky's  work  to  need  our  assur- 
ance that  this  is  one  of  the  most  profound,  thorough, 
and  valuable  books  ever  issued  from  the  medical 
press.  It  is  sui  generis,  and  has  no  standard  of  com- 
parison. It  is  only  necessary  to  announce  that  it  is 
issued  in  a  form  as  cheap  as  is  compatible  with  its 
size  and  preservation,  and  its  sale  follows  as  a 
matter  of  course.  No  library  can  be  called  com- 
plete without  it.— Buffalo  Med.  Journal. 

An  attempt  to  give  our  readers  any  adequate  idea 
of  the  vast  amount  of  instruction  accumulated  in 
these  volumes,  would  be  feeble  and  hopeless.  The 
effort  of  the  distinguished  author  to  concentrate 
in  a  small  space  his  great  fund  of  knowledge,  has 


so  charged  his  text  with  valuable  truths,  that  any 
attempt  of  a  reviewer  to  epitomize  is  at  once  para- 
lyzed, and  must  end  in  a  failure. — Western  Lancet. 

As  this  is  the  highest  source  of  knowledge  upon 
the  important  subject  of  which  it  treats,  no  real 
student  can  afford  to  be  without  it.  The  American 
publishers  have  entitled  themselves  to  the  thanks  of 
the  profession  of  their  country,  for  this  timeous  and 
beautiful  edition. — Nashville  Journal  of  Medicine. 

As  a  book  of  reference,  therefore,  this  work  must 
prove  of  inestimable  value,  and  we  cannot  too  highly 
recommend  it  to  the  profession.-—  Charleston  Med. 
Journal  and  Review,  Jan.  1856. 

This  book  is  a  necessity  to  every  practitioner. — 
Am.  Med.  Monthly. 


SCHOEDLER  (FRIEDRICH),  PH.D., 

Professor  of  the  Natural  Sciences  at  Worms,  &c. 

THE  BOOK  OF  NATURE;   an  Elementary  Introduction  to  the  Sciences  of 

Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany,  Zoology,  and  Physiology.  First 
American  edition,  with  a  Glossary  and  other  Additions  and  Improvements;  from  the  second 
English  edition.  Translated  from  the  sixth  German  edition,  by  Henry  Mkdlock,  F.  C.  S.,  &c. 
In  one  volume,  small  octavo,  extra  cloth,  pp.  692,  with  679  illustrations.    $1  80. 


28 


BLANCHARD    &   LEA'S    MEDICAL 


SMITH    (HENRY    H.),    M.  D., 

Professor  of  Surgery  in  the  University  of  Pennsylvania,  &c. 

MINOR  SURGERY;  or,  Hints  on  the  E very-day  Duties  of  the  Surgeon.  Illus- 
trated by  two  hundred  and  forty-seven  illustrations.  Third  and  enlarged  edition.  In  oneghand- 
some  royal  12mo.  volume,    pp.  456.     In  leather,  $2  25;  extra  cloth,  $2  00. 

A  work  such  as  the  present  is  therefore  highly 


And  a  capital  little  book  it  is.  .  .  Minor  Surgery, 
we  repeat,  is  really  Major  Surgery,  and  anything 
which  teaches  it  is  worth  having.  So  we  cordially 
recommend  this  little  book  of  Dr.  Smith's.— Med. - 
Chir.  Review. 

This  beautiful  little  work  has  been  compiled  with 
a  view  to  the  wants  of  the  profession  in  the  matter 
of  bandaging,  &c.,and  well  and  ably  has  the  author 
performed  his  labors.  Well  adapted  to  give  the 
requisite  information  on  the  subjects  of  which  it 
treats. — Medical  Examiner. 

The  directions  are  plain,  and  illustrated  through- 
out with  clear  engravings. — London  Lancet. 

One  of  the  best  works  they  can  consult  on  the 
subject  of  which  it  treats. — Southern  Journal  of 
Medicine  and  Pharmacy. 

BY  THE  SAME  AUTHOR,   AND 

HORNER  (WILLIAM  E.),   M.D., 
Late  Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the  Human  Body. 

In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred  and  fifty  beautiful 
figures.    $3  00. 


useful  to  the  student,  and  we  commend  this  one 
to  their  attention. — American  Journal  of  Medical 
Sciences. 

No  operator,  however  eminent,  need  hesitate  to 
consult  this  unpretending  yet  excellentbook.  Those 
who  are  young  in  the  business  would  find  Dr.  Smith's 
treatise  a  necessary  companion,  after  once  under- 
standing its  true  character. — Boston  Med.  and  Surg. 
Journal. 

No  young  practitioner  should  be  without  this  little 
volume ;  and  we  venture  to  assert,  that  it  may  be 
consulted  by  the  senior  members  of  the  profession 
with  more  real  benefit,  than  the  more  voluminous 
works. — Western  Lancet. 


These  figures  are  well  selected,  and  present  a 
complete  and  accurate  representation  of  that  won- 
derful fabric,  the  human  body.  The  plan  of  this 
Atlas,  which  renders  it  so  peculiarly  convenient 
for  the  student,  and  its  superb  artistical  execution, 
have  been  already  pointed  out.    We  must  congratu- 


late the  student  upon  the  completion  of  this  Atlas, 
as  it  is  the  most  convenient  work  of  the  kind  that 
has  yet  appeared  ;  and  we  must  add,  the  very  beau- 
tiful manner  in  which  it  is  "  got  up"  is  so  creditable 
to  the  country  as  to  be  flattering  to  our  national 
pride. — American  Medical  Journal. 


SARGENT  (F.  W.),   M.  D. 
ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SURGERY. 

Second  edition,  enlarged.     One  handsome  royal  12mo.  vol.,  of  nearly  400  pages,  with  182  wood- 
cuts.   Extra  cloth,  $1  40;  leather,  $1 


50. 

This  very  useful  little  work  has  long  been  a  favor- 
ite with  practitioners  and  students.  The  recent  call 
for  a  new  edition  has  induced  its  author  to  make 
numerous  important  additions.  A  slight  alteration 
in  the  size  of  the  page  has  enabled  him  to  introduce 
the  new  matter,  to  the  extent  of  some  fifty  pages  of 
the  former  edition,  at  the  same  time  that  his  volume 
is  rendered  still  more  compact  than  its  less  compre- 
hensive predecessor.  A  double  gain  in  thus  effected, 
which,  in  a  vade-mecum  of  this  kind,  is  a  material 
improvement. — Am.  Medical  Journal . 

Sargent's  Minor  Surgery  has  always  been  popular, 
and  deservedly  so.  It  furnishes  that  knowledge  of  the 
most  frequently  requisite  performances  of  surgical 
art  which  cannot  be  entirely  understood  by  attend- 
ing clinical  lectures.  The  art  of  bandaging,  which 
is  regularly  taught  in  Europe,  is  very  frequently 
overlooked  by  teachers  in  this  country ;  the  student 
and  junior  practitioner,  therefore,  may  often  require 
that  knowledge  which  this  little  volume  so  tersely 
and  happily  supplies.    It  is  neatly  printed  and  copi- 


ously illustrated  by  the  enterprising  publishers,  and 
should  be  possessed  by  all  who  desire  to  be  thorough- 
ly conversant  with  the  details  of  this  branch  of  our 
art. — Charleston  Med.  Journ.  and  Review,  March, 
1856. 

A  work  that  has  been  so  long  and  favorably  known 
to  the  profession  as  Dr.  Sargent's  Minor  Surgery, 
needs  no  commendation  from  us.  We  would  remark, 
however,  in  this  connection,  that  minor  surgery  sel- 
dom gets  that  attention  in  our  schools  that  its  im- 
portance deserves.  Our  larger  works  are  also  very 
defective  in  their  teaching  on  these  small  practical 
points.  This  little  book  will  supply  the  void  which 
all  must  feel  who  have  not  studied  its  pages. — West- 
ern Lancet,  March,  1856. 

We  confess  our  indebtedness  to  this  little  volume 
on  many  occasions,  and  can  warmly  recommend  it 
to  our  readers,  as  it  is  not  above  the  consideration 
of  the  oldest  and  most  experienced. — American  Lan- 
cet, March,  1856. 


SKEY'S  OPERATIVE  SURGERY.  In  one  very 
handsome  octavo  volume,  extra  cloth,  of  over  650 
pages,  with  about  one  hundred  wood-cuts.  $3  25. 

STANLEY'S  TREATISE  ON  DISEASES  OF 
THE  BONES.  In  one  volume,  octavo,  extra  cloth, 
286  pages.    SI  50. 

SOLLY  ON  THE  HUMAN  BRAIN;  its  Structure, 
Physiology,  and  Diseases.    From  the  Second  and 


much  enlarged  London  edition.  In  one  octavo 
volume,  extra  cloth,  of  500  pages,  with  120  wood- 
cuts.   $2  00. 

SIMON'S  GENERAL  PATHOLOGY,  as  conduc- 
ive to  the  Establishment  of  Rational  Principles 
for  the  prevention  and  Cure  of  Disease.  In  one 
neat  octavo  volume,  extra  cloth,  of  212  pages. 
$1  25. 


STILLE  (ALFRED),   M.  D. 

PRINCIPLES    OF    GENERAL    AND    SPECIAL    THERAPEUTICSj     In 

handsome  octavo.    (Preparing.) 


SIBSON   (FRANCIS),    M.D., 

Physician  to  St.  Mary's  Hospital. 


MEDICAL  ANATOMY 

Internal  Organs  in  H< 
To  match  "Maclise's 


Illustrating  the  Form,  Structure,  and  Position  of  the 


Internal  Organs  in  Health  and  Disease.    In  large  imperial  quarto,  with  splendid  colored  plates. 
Surgical  Anatomy."    Part  I.    {Preparing.) 


AND    SCIENTIFIC    PUBLICATIONS. 


2!) 


SHARPEY  (WILLIAM),    M.  D.,    JONES   QUAIN,    M.D.,   AND 

RICHARD   QUAIN,    F.  R.  S.,  &c. 

HUMAN  ANATOMY.     Revised,  with  Notes  and  Additions,  by  Joseph  Leidy, 

M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.  Complete  in  two  large  octavo 
volumes,  leather,  of  about  thirteen  hundred  pages.  Beautifully  illustrated  with  over  five  hundred 
engravings  on  wood.     $6  00. 


It  is  indeed  a  work  calculated  to  make  an  era  in 
anatomical  study,  by  placing  before  the  student 
every  department  of  his  science,  with  a  view  to 
the  relative  importance  of  each ;  and  so  skilfully 
have  the  different  parts  been  interwoven,  that  no 
one  who  makes  this  work  the  basis  of  his  studies, 
will  hereafter  have  any  excuse  for  neglecting  or 
undervaluing  any  important  particulars  connected 
with  the  structure  of  the  human  frame;  and 
whether  the  bias  of  his  mind  lead  him  in  a  more 
especial  manner  to  surgery,  physic,  or  physiology, 


he  will  find  here  a  work  at  once  so  comprehensive 
and  practical  as  to  defend  him  from  exclusiveness 
on  the  one  hand,  and  pedantry  on  the  other. — 
Journal  and  Retrospect  of  the  Medical  Sciences. 
We  have  no  hesitation  in  recommending  this  trea- 
tise on  anatomy  as  the  most  complete  on  that  sub- 
ject in  the  English  language;  and  the  only  one, 
perhaps,  in  any  language,  which  brings  the  state 
of  knowledge  forward  to  the  most  recent  disco- 
veries.— The  Edinburgh  Med.  and  Surg.  Journal. 


SMITH   (W.   TYLER),  M.  D., 

Physician  Accoucheur  to  St.  Mary's  Hospital,  &c. 

ON   PARTURITION,   AND   THE    PRINCIPLES    AND   PRACTICE   OF 

OBSTETRICS.    In  one  royal  12mo.  volume,  extra  cloth,  of  400  pages.    $1  25. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PATHOLOGY  AND  TREATMENT 

OF  LEUCORRHCEA.    With  numerous  illustrations.    In  one  very  handsome  octavo  volume, 
extra  cloth,  of  about  250  pages.     $1  50. 

We  hail  the  appearance  of  this  practical  and  invaluable  work,  therefore,  as  a  real  acquisition  to  our 
medical  literature. — Medical  Gazette. 


TAYLOR  (ALFRED  S.),  M.  D.,  F.  R.  S., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.  Fourth  American,  from  the  fifth  improved  and 
enlarged  English  Edition.  With  Notes  and  References  to  American  Decisions,  by  Edward 
Hartshorne,  M.  D.  In  one  large  octavo  volume,  leather,  of  over  seven  hundred  pages.  (Just 
Issued,  1856.)    $3  00. 

This  standard  work  has  lately  received  a  very  thorough  revision  at  the  hands  of  the  author,  who 
has  introduced  whatever  was  necessary  to  render  it  complete  and  satisfactory  in  carrying  out  the 
objects  in  view.  The  editor  has  likewise  used  every  exertion  to  make  it  equally  thorough  with 
regard  to  all  matters  relating  to  the  practice  of  this  country.  In  doing  this,  he  has  carefully  ex- 
amined all  tha\has  appeared  on  the  subject  since  the  publication  of  the  last  edition,  and  has  incorpo- 
rated all  the  ne\  information  thus  presented.  The  work  has  thus  been  considerably  increased  in 
size,  notwithstanding  which,  it  has  been  kept  at  its  former  very  moderate  price,  and  in  every  respect 
it  will  be  found  worthy  of  a  continuance  of  the  remarkable  favor  which  has  carried  it  through  so 
many  editions  on  both  sides  of  the  Atlantic.    A  few  notices  of  the  former  editions  are  appended. 

We  know  of  no  work  on  Medical  Jurisprudence 
Which  contains  in  the  same  space  anything  like  the 
same  amount  of  valuable  matter. — N.  Y.  Journal  of 


Medicine 

No  work  upon  the  subject  can  be  put  into  the 
hands  of  students  either  of  law  or  medicine  which 
will  engage  them  more  closely  or  profitably  ;  and 
none  eoufd  be  offered  to  the  busy  practitioner  of 
either  calling,  for  the  purpose  of  casual  or  hasty 
reference,  that  would  be  more  likely  to  afford  the  aid 
desired.  We  therefore  recommend  it  as  the  best  and 
safest  manual  for  daily  use. — American  Journal  of 
Medical  Sciences. 

This  work  of  Dr.  Taylor's  is  generally  acknow- 
ledged to  be  one  of  the  ablest  extant  on  the  subject 
of  medical  jurisprudence.  It  is  certainly  one  of  the 
most  attractive  books  that  we  have  met  with  ;  sup- 
plying so  much  both  to  interest  and  instruct,  that 


we  do  not  hesitate  to  affirm  that  after  having  once 
commenced  its  perusal,  few  could  be  prevailed  upon 
to  desist  before  completing  it.  In  the  last  London 
edition,  all  the  newly  observed  and  accurately  re- 
corded facts  have  been  inserted,  including  much  that 
is  recent  of  Chemical,  Microscopical,  and  Patholo- 
gical research,  besides  papers  on  numerous  subjects 
never  before  published.-C  harleston  Medical  Journal 
and  Review. 

It  is  not  excess  of  praise  to  say  that  the  volume 
before  us  is  the  very  best  treatise  extant  on  Medical 
Jurisprudence.  In  saying  this,  we  do  not  wish  to 
be  understood  as  detracting  from  the  merits  of  the 
excellent  works  of  Beck,  Ryan,  Traill,  Guy,  and 
others;  but  in  interest  and  value  we  think  it  must 
be  conceded  that  Taylor  is  superior  to  anything  that 
has  preceded  it. — N.  W.  Medical  and  Surg.  Journal. 


BY    THE   SAME    AUTHOR. 

ON  POISONS,  IN  RELATION  TO   MEDICAL  JURISPRUDENCE  AND 

MEDICINE.  Edited,  with  Notes  and  Additions,  by  R.  E.  Griffith,  M.  D.  In  one  large  octavo 
volume,  leather,  of  688  pages.    |3  00 

TANNER   (T.    H.),    M.  D., 

Physician  to  the  Hospital  for  Women,  &c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS. 

To  which  is  added  The  Code  of  Ethics  of  the  American  Medical  Association.  Second 
American  Edition.  In  one  neat  volume,  small  12mo.  Price  in  extra  cloth,  87$  cents  ;  flexible 
style,  for  the  pocket,  80  cents. 


The  work  is  an  honor  to  its  writer,  and  must  ob- 
tain a  wide  circulation  by  its  intrinsic  merit  alone. 
Suited  alike  to  the  wants  of  students  and  practi- 
tioners, it  has  only  to  be  seen,  to  win  for  itself  a 
place  upon  the  shelves  of  every  medical  library. 
Nor  will  it  be  "  shelved"  long  at  a  time ;  if  we  mis- 
take not,  it  will  be  found,  in  the  best  sense  of  the 


homely  but  expressive  word,  "  handy."  The  style 
is  admirably  clear,  while  it  is  so  sententious  as  not 
to  burden  the  memory.  The  arrangement  is,  to  our 
mind,  unexceptionable.  The  work,  in  short,  de- 
serves the  heartiest  commendation.— B oston  Med. 
and  Surg.  Journal'. 


30 


BLANCHARD    &    LEA'S   MEDICAL 


Now  Complete  (April,  1857.) 
TODD  (ROBERT  BENTLEY),  M.  D.,  F.  R.  S., 

Professor  of  Physiology  in  King's  College,  London;  and 
WILLIAM  BOWMAN,  F.  R.  S., 

Demonstrator  of  Anatomy  in  King's  College,  London. 

THE  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN.    With 

about  three  hundred  large  and  beautiful  illustrations  on  wood.     Complete  in  one  large  octavo 

volume,  of  950  pages,  leather.     Price  $4  50. 

The  very  great  delay  which  has  occurred  in  the  completion  of  this  work  has  arisen  from  the  de- 
sire of  the  authors  to  verify  by  their  own  examination  the  various  questions  and  statements  pre- 
sented, thus  rendering  the  work  one  of  peculiar  value  and  authority.  By  the  wideness  of  its  scope 
and  the  accuracy  of  its  facts  it  thus  occupies  a  position  of  its  own,  and  becomes  necessary  to  all 
physiological  students. 

t^3  Gentlemen  who  have  received  portions  of  this  work,  as  published  in  the  "  Medical  News 
and  Library,"  can  now  complete  their  copies,  if  immediate  application  be  made.  It  will  be  fur- 
nished as  follows,  free  by  mail,  in  paper  covers,  with  cloth  backs. 

Parts  I.,  II.,  III.  (pp.  25  to  552),  $2  50. 

Part  IV.  (pp.  553  to  end,  with  Title,  Preface,  Contents,  &c),  $2  00. 

Or,  Part  IV.,  Section  II.  (pp.  725  to  end,  with  Title,  Preface,  Contents,  &c),  $1  25. 

A  magnificent  contribution  to  British  medicine, 
and  the  American  physician  who  shall  fail  to  peruse 
it,  will  have  failed  to  read  one  of  the  most  instruc- 


tive books  of  the  nineteenth  century. — N.  O.  Med 
and  Surg.  Journal,  Sept.  1857. 

It  is  more  concise  than  Carpenter's  Principles,  and 
more  modern  than  the  accessible  edition  of  Mailer's 
Elements;  its  details  are  brief,  but  sufficient;  its 
descriptions  vivid  ;  its  illustrations  exact  and  copi- 
ous ;  and  its  language  terse  and  perspicuous. — 
Charleston  Med.  Journal,  July,  1857. 

We  recommend  this  work  not  only  for  its  many 
original  investigations  especially  into  the  minute 
anatomy  and  physiology  of  man,  but  we  admire  the 
constant  association  of  anatomy  with  physiology. 
The  motive  power  is  studied  in  its  connections  and 
adaptations  to  the  machine  it  is  destined  to  guide, 
and  the  student  feels  constantly  impressed  with  the 
necessity  for  an  accurate  knowledge  of  the  structure 
of  the  human  body  before  he  can  make  himself  mas- 
ter of  its  functions. —  Va.  Med.  Journal,  June,  1857. 

We  know  of  no  work  on  the  subject  of  physiology 
so  well  adapted  to  the  wants  of  the  medical  student. 
Its  completion  has  been  thus  long  delayed,  that  the 
authors  might  secure  accuracy  by  personal  observa- 
tion.— St.  Louis  Med.  and  Surg.  Journal,  Sept.  '57. 


One  of  the  very  best  books  ever  issued  from  any 
medical  press.  We  think  it  indispensable  to  every 
reading  medical  man,  and  it  may,  with  all  propriety, 
and  with  the  utmost  advantage  be  made  a  text-book 
by  any  student  who  would  thoroughly  comprehend 
the  groundwork  of  medicine. — N.  O.  Med.  News, 
June, 1857. 

Our  notice,  though  it  conveys  but  a  very  feeble 
and  imperfect  idea  of  the  magnitude  and  importance 
of  the  work  now  under  consideration,  already  tran- 
scends our  limits  ;  and,  with  the  indulgtnce  of  our 
readers,  and  the  hope  that  they  will  peruse  the  book 
for  themselves,  as  we  feel  we  can  with  confidence 
recommend  it,  we  leave  it  in  their  hands  for  them 
to  judge  of  its  merits. — The  Northwestern  Med.  and 
Surg.  Journal,  Oct.  1857. 

It  has  been  a  far  more  pleasant  task  to  us  to  point 
out  its  features  of  remarkable  excellence,  and  to 
show  in  how  many  particulars  the  results  which  it 
embodies  of  skilful  and  zealous  research  do  the 
highest  credit  to  its  able  and  accomplished  authors. 
It  would  be  a  serious  omission  were  we  not  to  take 
special  notice  of  the  admirable  and  copious  illustra- 
tions, the  execution  of  which  (by  Mr.  Vasey)  is  in 
the  very  finest  style  of  wood-engraving. — Brit,  and 
For.  Medico-Chir.  Revieyo,  Jan.  1858. 


TODD  (R.   B.),   M.  D.,    F.  R.  S.,   &c. 
CLINICAL  LECTURES  ON  CERTAIN  DISEASES  OF  THE  URINARY 

ORGANS  AND  ON  DROPSIES.    In  one  octavo  volume.    {Now  Ready,  1857.)    $1  50. 

The  valuable  practical  nature  of  Dr.  Todd's  writings  have  deservedly  rendered  them  favorites 
with  the  profession,  and  the  present  volume,  embodying  the  medical  aspects  of  a  class  of  diseases 
not  elsewhere  to  be  found  similarly  treated,  can  hardly  fail  to  supply  a  want  long  felt  by  the  prac- 
titioner 


&c, 


WATSON   (THOMAS),    M 
LECTURES    ON    THE   PRINCIPLES    AND    PRACTICE    OF   PHYSIC. 

Third  American  edition,  revised,  with  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of  a 


Treatise  on  the  Diseases  of  Children,"  &e 
large  pages,  strongly  bound  with  raised  bands. 
To  say  that  it  is  the  very  best  work  on  the  sub- 
ject now  extant,  is  but  to  echo  the  sentiment  of  the 
medical    press    throughout    the   country.  —  N.   O. 
Medical  Journal. 

Of  the  text-books  recently  republished  Watson  is 
very  justly  the  principal  favorite. — Holmes's  Rep. 
to  Nat.  Med.  Assoc. 

By  universal  consent  the  work  ranks  among  the 
very  best  text-books  in  our  language. — Illinois  and 
Indiana  Med.  Journal. 

Regarded  on  all  hands  as  one  of  the  very  best,  if 
not  the  very  best,  systematic  treatise  on  practical 
medicine  extant. — St.  Louis  Med.  Journal. 


In  one  octavo  volume,  of  nearly  eleven  hundred 

$3  25. 

Confessedly  one  of  the  very  best  works  on  the 
principles  and  practice  of  physic  in  the  English  or 
any  other  language. — Med.  Examiner. 

Asa  text-book  it  has  no  equal ;  as  a  compendium 
of  pathology  and  practice  no  superior. — New  York 
Annalist. 

We  know  of  no  work  better  calculated  for  being 
placed  in  the  hands  of  the  student,  and  for  a  text- 
book; on  every  important  point  the  author  seems 
to  have  posted  up  his  knowledge  to  the  day. — 
Amer.  Med.  Journal. 

One  of  the  most  practically  useful  books  that 
ever  was  presented  to  the  student.  —  N.  Y.  Med. 
Journal. 


WHAT   TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER   DEATH,   IN    MEDICAL    CASES. 

Published  under  the  authority  of  the  London  Society  for  Medical  Observation.    A  new  American, 

from  the  second  and  revised  London  edition.    In  one  very  handsome  volume,  royal  12mo.,  extra 

cloth.    $1  00. 

To  the  observer  who  prefers  accuracy  to  blunders  I      One  of  the  finest  aids  to  a  young  practitioner  we 
and  precision  to  carelessness,  this  little  book  is  in-    have  ever  seen. — Peninsular  Journal  of  Medicine. 
valuable. — N.  II.  Journal  of  Medicine.  \ 


AND    SCIENTIFIC    PUBLICATIONS 


31 


WILSON    (ERASMUS),   M.D.,    F.  R.  S., 

Lecturer  on  Anatomy,  London. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Fourth  Ameri- 
can, from  the  last  English  edition.  Edited  by  Paul  B.  Goddard,  A.  M.,  M.  D.  With  two  hun- 
dred and  fifty  illustrations.  Beautifully  printed,  in  one  large  octavo  volume,  leather,  of  nearly 
six  hundred  pages.     $3  00. 


In  many,  if  not  all  the  Colleges  of  the  Union,  it 
has  become  a  standard  text-book.  This,  of  itself, 
is  sufficiently  expressive  of  its  value.  A  work  very 
desirable  to  the  student;  one,  the  possession  of 
which  will  greatly  facilitate  his  progress  in  the 
study  of  Practical  A natomy .— New  York  Journal  of 
Medicine. 

Its  author  ranks  with  the  highest  on  Anatomy. — 
Southern  Medical  and  Surgical  Journal. 


It  offers  to  the  student  all  the  assistance  that  can 
be  expected  from  such  a  work. — Medical  Examiner. 

The  most  complete  and  convenient  manual  for  the 
student  we  possess.— American  Journal  of  Medical 
Science. 

In  every  respect,  this  work  as  an  anatomical 
guide  for  the  student  and  practitioner,  merits  our 
warmest  and  most  decided  praise. — London  Medical 
Gazette. 


BY   THE   SAME   AUTHOR.      (Just  Issued.) 

THE    DISSECTOR'S  MANUAL;  or,  Practical  and  Surgical  Anatomy.     Third 

American,  from  the  last  revised  and  enlarged  English  edition.  Modified  and  rearranged,  by 
William  Hunt,  M.  D.,  Demonstrator  of  Anatomy  in  the  University  of  Pennsylvania.  In  one 
large  and  handsome  royal  12mo.  volume,  leather,  of  582  pages,  with  154  illustrations.  $2  00. 
The  modifications  and  additions  which  this  work  has  received  in  passing  recently  through  the 
author's  hands,  is  sufficiently  indicated  by  the  fact  that  it  is  enlarged  by  more  than  one  hundred 
pages,  notwithstanding  that  it  is  printed  in  smaller  type,  and  with  a  greatly  enlarged  page. 

It  remains  only  to  add,  that  after  a  careful  exami- 
nation, we  have  no  hesitation  in  recommending  this 
work  to  the  notice  of  those  for  whom  it  has  been 


ing  very  superior  claims,  well  calculated  to  facilitate 
their  studies,  and  render  their  labor  less  irksome,  by 
constantly  keeping  before  them  definite  objects  of 
interest. — The  Lancet. 


expressly  written— the  students— as  a  guide  possess 

BY  the  same  author.     {Now  Ready,  May,  1857.) 

ON  DISEASES  OF  THE  SKIN.  Fourth  and  enlarged  American,  from  the  last 
and  improved  London  edition.  In  one  large  octavo  volume,  of  650  pages,  extra  cloth,  $2  75. 
This  volume  in  passing  for  the  fourth  time  through  the  hands  of  the  author,  has  received  a  care- 
ful revision,  and  has  been  greatly  enlarged  and  improved.  About  one  hundred  and  fifty  pages  have 
been  added,  including  new  chapters  on  Classification,  on  General  Pathology,  on  General  Thera- 
peutics, on  Furuncular  Eruptions,  and  on  Diseases  of  the  Nails,  besides  extensive  additions  through- 
out the  text,  wherever  they  have  seemed  desirable,  either  from  former  omissions  or  from  the  pro- 
gress of  science  and  the  increased  experience  of  the  author.  Appended  to  the  volume  will  also 
now  be  found  a  collection  of  Selected  Formulae,  consisting  for  the  most  part  of  prescriptions  of 
which  the  author  has  tested  the  value. 


The  writings  of  Wilson,  upon  diseases  of  the  skin, 
are  by  far  the  most  scientific  and  practical  that 
have  ever  been  presented  to  the  medical  world  on 
this  subject.  The  present  edition  is  a  great  improve- 
ment on  all  its  predecessors.  To  dwell  upon  all  the 
great  merits  and  high  claims  of  the  work  before  us, 
seriatim,  would  indeed  be  an  agreeable  service;  it 
would  be  a  mental  homage  which  we  could  freely 
offer,  but  we  should  thus  occupy  an  undue  amount 
of  space  in  this  Journal.  We  will,  however,  look 
at  some  of  the  more  salient  points  with  which  it 
abounds,  and  which  make  it  incomparably  superior  in 
excellence  to  all  other  treatises  on  the  subject  of  der- 
matology.   No  mere  speculative  views  are  allowed 


a  place  in  this  volume,  which,  without  a  doubt,  will , 
for  a  very  long  period,  be  acknowledged  as  the  chief 
standard  work  on  dermatology.  The  principles  of 
an  enlightened  and  rational  therapeia  are  introduced 
on  every  appropriate  occasion.  The  general  prac- 
titioner and  surgeon  who,  peradventure,  may  have 
for  years  regarded  cutaneous  maladies  as  scarcely 
worthy  their  attention,  because,  forsooth,  they  are 
not  fatal  in  their  tendency;  or  who,  if  they  have 
attempted  their  cure,  have  followed  the  blind  guid- 
ance of  empiricism,  will  almost  assuredly  be  roused 
to  a  new  and  becoming  interest  in  this  department 
of  practice,  through  the  inspiring  agency  of  this 
book. — Am.  Jour.  Med.  Science,  Oct.  1857. 


ALSO,  JUST  READY, 

A  SERIES  OF  PLATES  ILLUSTRATING  WILSON  ON  DISEASES   OF 

THE  SKIN  ;  consisting  of  nineteen  beautifully  executed  plates,  of  which  twelve  are  exquisitely 
colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin,  and  containing  accurate  re- 
presentations of  about  one  hundred  varieties  of  disease,  most  of  them  the  size  of  nature.  Price 
in  cloth  $4  25. 

In  beauty  of  drawing  and  accuracy  and  finish  of  coloring  these  plates  will  be  found  superior  to 
anything  of  the  kind  as  yet  issued  in  this  country. 

The  plates  by  which  this  edition  is  accompanied  I  The  representations  of  the  various  forms  of  cutane-" 

leave  nothing  to  be  desired,  so  far  as  excellence  of  j  ous  disease  are  singularly  accurate,  and  the  coloring 

delineation  and  perfect  accuracy  of  illustration  are  |  exceeds  almost  anything  we  have  met  with  in  point 

concerned. — Medico-Chirurgical  Review.  of  delicacy  and  finish. — British  and  Foreign  Medical 

Of  these  plates  it  is  impossible  to  speak  too  highly.  |  Reviev}- 

BY   THE   SAME   AUTHOR. 

ON    CONSTITUTIONAL    AND    HEREDITARY    SYPHILIS,   AND    ON 

SYPHILITIC  ERUPTIONS.  In  one  small  octavo  volume,  extra  cloth,  beautifully  printed,  with 
four  exquisite  colored  plates,  presenting  more  than  thirty  varieties  of  syphilitic  eruptions.  $2  25. 

BY   THE   SAME   AUTHOR.      {Just  Issued.) 

HEALTHY  SKIN;  A  Popular  Treatise  on  the  Skin  and  Hair,  their  Preserva- 
tion and  Management.  Second  American,  from  the  fourth  London  edition.  One  neat  volume, 
royal  12mo.,  extra  cloth,  of  about  300  pages,  with  numerous  illustrations.  $1  00 ;  paper  cover, 
75  cents. 

WILDE   (W.    R.), 

Surgeon  to  St.  Mark's  Ophthalmic  and  Aural  Hospital,  Dublin. 

AURAL  SURGERY,  AND  THE  NATURE  AND  TREATMENT  OF  DIS- 
EASES OF  THE  EAR.  In  one  handsome  octavo  volume,  extra  cloth,  of  476  pages,  with 
illustrations.    $2  80. 


32  BLANCHARD    &   LEA'S    MEDICAL    PUBLICATIONS. 

WEST   (CHARLES),    M.  D., 

Accoucheur  to  and  Lecturer  on  Midwifery  at  St.  Bartholomew's  Hospital,  Physician  to  the  Hospital  for 

Sick  Children,  &c. 

LECTURES   ON   THE   DISEASES   OF  INFANCY  AND  CHILDHOOD. 

Second  American,  from  the  Second  and  Enlarged  London  edition.      In  one  volume,  octavo, 
extra  cloth,  of  nearly  five  hundred  pages.    $2  00. 


ligation  by  this  able,  thorough,  and  finished  work 
upon  a  subject  which  almost  daily  taxes  to  the  ut- 
most the  skill  of  the  general  practitioner.  He  has 
with  singular  felicity  threaded  his  way  through  all 
the  tortuous  labyrinths  of  the  difficult  subject  he  has 
undertaken  to  elucidate,  and  has  in  many  of  the 
darkest  corners  left  a  light,  which  will  never  be 
extinguished. — Nashville  Medical  Journal. 


We  take  leave  of  Dr.  West  with  great  respect  for 
his  attainments,  a  due  appreciation  of  his  acute 
powers  of  observation,  and  a  deep  sense  of  obliga- 
tion for  this  valuable  contribution  to  our  profes- 
sional literature.  His  book  is  undoubtedly  in  many 
respects  the  best  we  possess  on  diseases  of  children. 
Dublin  Quarterly  Journal  of  Medical  Science. 

Dr.  West  has  placed  the  profession  under  deep  ob- 

•  BY    THE   SAME   AUTHOR.      (Just  Isstted.) 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     In  two  parts. 

Part  I.  8vo.  cloth,  of  about  300  pages,  comprising  the  Diseases  of  the  Uterus.     SI  60. 
Part  II.  (Preparing),  will  contain  Diseases  of  the  Ovaries,  and  of  all  the  parts,  connected 

with  the  Uterus  ;  of  the  Bladder,  Vagina,  and  External  Organs. 
The  objoct  of  the  author  in  this  work  is  to  present  a  complete  but  succinct  treatise  on  Female 
Diseases,  embodying  the  results  of  his  experience  during  the  last  ten  years  at  St.  Bartholomew's 
and  the  Midwifery  Hospitals,  as  well  as  in  private  practice.  The  characteristics  which  have  se- 
cured to  his  former  works  so  favorable  a  reception,  cannot  fail  to  render  the  present  volume  a 
standard  authority  on  its  important  subject.  To  show  the  general  scope  of  the  work,  an  outline  of 
the  Contents  of  Part  I.  is  subjoined. 

Lectures  I,  II—  Introductory— Symptoms— Examination  of  Symptoms— Modes  of  Examina- 
tions. Lectures  III,  IV.,  V — Disorders  of  Menstruation,  Amenorrhoea,  Menorrhagia,  Dys- 
menorrhoea.  Lectures  VI.,  VII,  VIII—  Inflammation  of  the  Uterus,  Hypertrophy,  Acute 
Inflammation,  Chronic  Inflammation,  Ulceration  of  the  Os  Uteri,  Cervical  Leucorrhoea.  Lectures 
IX.,  X.,  XI,  XII,  XIII— Misplacement  of  the  Uterus,  Prolapsus,  Anteversion,  Retrover- 
sion, Inversion.  Lectures  XIV.,  XV.,  XVI,  XVII— Uterine  Tumors  and  Outgrowths, 
Mucous,  Fibro-cellular,  and  Glandular  Polypi,  Mucous  Cysts,  Fibrinous  Polypi,  Fibrous  Tumors, 
Fibrous  Polypi,  Fatty  Tumors,  Tubercular  Diseases.  Lectures  XVIII,  XIX.,  XX. — Cancer 
of  the  Uterus. 
Part  II.  will  receive  an  equally  extended  treatment,  rendering  the  whole  an  admirable  text-book 
for  the  student,  and  a  reliable  work  for  reference  by  the  practitioner. 

BY  THE  SAME  AUTHOR.      (Just  Issued) 

AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OF  ULCER- 
ATION OF  THE  OS  UTERI.    In  one  neat  octavo  volume,  extra  cloth.    $1  00. 


WILLIAMS  (C.   J.  B.),    M.  D.,    F.  R.  S., 

.      Professor  of  Clinical  Medicine  in  University  College,  London,  fee. 

PRINCIPLES  OF  MEDICINE.     An  Elementaiy  View  of  the  Causes,  Nature, 

Treatment,  Diagnosis,  and  Prognosis  of  Disease ;  with  brief  remarks  on  Hygienics,  or  the  pre- 
servation of  health.  A  new  American,  from  the  third  and  revised  London  edition,  la  one  octavo 
volume,  leather,  of  about  500  pages.     $2  50.     (Now  Ready,  May,  1857.) 

The  very  recent  and  thorough  revision  which  this  work  has  enjoyed  at  the  hands  of  the  author 
has  brought  it  so  completely  up  to  the  present  state  of  the  subject  that  in  reproducing  it  no  additions 
have  been  found  necessary. '  The  success  which  the  work  has  heretofore  met  shows  that  its  im- 
portance has  been  appreciated,  and  in  its  present  form  it  will  be  found  eminently  worthy  a  continu- 
ance of  the  same  favor,  possessing  as  it  does  the  strongest  claims  to  the  attention  of  the  medical 
student  and  practitioner,  from  the  admirable  manner  in  which  the  various  inquiries  in  the  different 
branches  of  pathology  are  investigated,  combined  and  generalized  by  an  experienced  practical  phy- 
sician, and  directly  applied  to  the  investigation  and  treatment  of  disease. 

recommend  it  for  a  text-book,  guide,  and  constant 
companion  to  every  practitioner  and  every  student 
who  wishes  to  extricate  himself  from  the  well-worn 


We  find  that  the  deeply-interesting  matter  and 
style  of  this  book  have  so  far  fascinated  us,  that  we 
have  unconsciously  hung  upon  its  pages,  not  too 
long,  indeed,  for  our  own  profit,  but  longer  than  re- 
viewers can  be  permitted  to  indulge.  We  leave  the 
further  analysis  to  the  student  and  practitioner.  Our 
judgment  of  the  work  has  already  been  sufficiently 
expressed.  It  is  a  judgment  of  almost  unqualified 
praise.  The  work  is  not  of  a  controversial,  but  of 
a  didactic  character :  and  as  such  we  hail  it,  and 


ruts  of  empiricism,  and  to  base  his  practice  of  medi- 
cine upon  principles. — London  Lancet,  Dec. 27, 1856. 

A  text-book  to  which  no  other  in  our  language  is 
comparable. — Charleston  Medical  Journal. 

No  work  has  ever  achieved  or  maintained  a  more 
deserved  reputation. —  Va.  Med.  and  Surg.  Journal. 


WHITEHEAD  ON  THE  CAUSES  AND  TREAT-  I      Second  American  Edition.    In  one  volume,  octa- 
MBNT   OF    ABORTION    AND  STERILITY.  |      vo,  extra  cloth,  pp.  308.    $1    75. 


YOUATT  (WILLIAM),  V.  S. 
THE    HORSE.     A  new  edition,  with  numerous  illustrations;   together  with  a 

general  history  of  the  Horse ;  a  Dissertation  on  the  American  Trotting  Horse ;  how  Trained  and 
Jockeyed ;  an  Account  of  his  Remarkable  Performances ;  and  an  Essay  on  the  Ass  and  the  Mule. 
By  J.  S.  Skinner,  formerly  Assistant  Postmaster-General,  and  Editor  of  the  Turf  Register. 
One  large  octavo  volume,  extra  cloth.    $1  50. 

BY   THE   SAME   AUTHOR. 

THE  DOG.     Edited  by  E.  J*.  Lewis,   M.  D.     With  numerous  and  beautiful 

illustrations-    In  one  very  handsome  volume,  crown  Svo.,  crimson  cloth,  gilt.  $1  25. 


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